Modifications of lung microbiota structure in traumatic brain injury ventilated patients according to time and enteral feeding formulas: a prospective randomized study

BACKGROUND

Specialized diets enriched with immune nutrients could be an important supplement in patients (pts) with acute traumatic brain injury (TBI). Omega-3 and arginine may interact with immune response and microbiota. No data are available about the role of the specialized diets in modulating the lung microbiota, and little is known about the influence of lung microbiota structure in development of ventilator-associated pneumonia (VAP) in TBI pts. The aims of this study are to evaluate the impact of specific nutrients on the lung microbiota and the variation of lung microbiota in TBI pts developing VAP.

METHODS

A cohort of 31 TBI pts requiring mechanical ventilation in ICU was randomized for treatment with specialized (16pts) or standard nutrition (15pts). Alpha and beta diversity of lung microbiota were analyzed from bronco Alveolar Lavage (BAL) samples collected at admission and 7 days post-ICU admission in both groups. A further analysis was carried out on the same samples retrospectively grouped in VAP or no VAP pts.

RESULTS

None developed VAP in the first week. Thereafter, ten out of thirty-one pts developed VAP. The BAL microbiota on VAP group showed significant differences in beta diversity and Staphylococcus and Acinetobacter Genera were high. The specialized nutrition had influence on beta diversity that reached statistical significance only in Bray-Curtis distance.

CONCLUSION

Our data suggest that TBI patients who developed VAP during ICU stay have different structures of BAL microbiota either at admission and at 7 days post-ICU admission, while no correlation has been observed between different enteral formulas and microbiota composition in terms of richness and evenness. These findings suggest that targeting the lung microbiota may be a promising approach for preventing infections in critically ill patients.

Students Eat Less Meat After Studying Meat Ethics

In the first controlled, non-self-report studies to show an influence of university-level ethical instruction on everyday behavior, Schwitzgebel et al. (2020) and Jalil et al. (2020) found that students purchase less meat after exposure to material on the ethics of eating meat. We sought to extend and conceptually replicate this research. Seven hundred thirty students in three large philosophy classes read James Rachels' (2004) "Basic Argument for Vegetarianism", followed by 50-min small-group discussions. Half also viewed a vegetarianism advocacy video containing factory farm footage. A few days after instruction, 54% of students agreed that "eating the meat of factory farmed animals is unethical", compared to 37% before instruction, with no difference between the film and non-film conditions. Also, 39% of students anonymously pledged to avoid eating factory farmed meat for 24 h, again with no statistically detectable difference between conditions. Finally, we obtained 2828 campus food purchase receipts for 113 of the enrolled students who used their Student ID cards for purchases on campus, which we compared with 5033 purchases from a group of 226 students who did not receive the instruction. Meat purchases remained constant in the comparison group and declined among the students exposed to the material, falling from 30% to 23% of purchases overall and from 51% to 42% of purchases of $4.99 or more, with the effect possibly larger in the film condition.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13164-021-00583-0.

“We Need to Think of Future Generations and of Non-human Animals” An Interview with Peter Singer, Australian Philosopher, World-Famous Animal Ethicist

Interview with Peter Singer, Australian philosopher, world-famous animal ethicist

A bolder One Health: expanding the moral circle to optimize health for all

One Health is a ground-breaking philosophy for improving health. It imaginatively challenges centuries-old assumptions about wellbeing and is now widely regarded as the 'best solution' for mitigating human health problems, including pandemic zoonotic diseases. One Health's success is imperative because without big changes to the status quo, great suffering and ill-health will follow. However, even in its more ambitious guises, One Health is not radical enough. For example, it has not embraced the emerging philosophical view that historical anthropocentrism is an unfounded ethical prejudice against other animals. This paper argues that One Health should be more imaginative and adventurous in its core philosophy and ultimately in its recommendations and activities. It must expand the circle of moral concern beyond a narrow focus on human interests to include nonhuman beings and the environment. On this bolder agenda, progressive ethical and practical thinking converge for the benefit of the planet and its diverse inhabitants-human and nonhuman.

Analyses and Declarations of Omega-3 Fatty Acids in Canned Seafood May Help to Quantify Their Dietary Intake

The American Heart Association (AHA) recently confirmed common recommendations of one to two fish dishes per week in order to prevent cardiovascular disease (CVD). Nevertheless, the natural fluctuations of lipids and fatty acids (FA) in processed seafood caught little public attention. Moreover, consumers of unprocessed seafood in general do not know how much omega-3 fatty acids (omega-3 FA) within servings they actually ingest. The few studies published until today considering this aspect have been re-evaluated in today’s context. They included four observational studies with canned fatty coldwater fish (mackerel and herring from the same region, season, producer and research group). Their outcomes were similar to those conducted in the following years using supplements. Cans containing seafood (especially fatty coldwater fish) with declared content of omega-3 FA are ready-to-use products. Human studies have shown a higher bioavailability of omega-3 FA by joint uptake of fat. Canned fatty coldwater fish contain omega-3 FA plus plenty of fat in one and the same foodstuff. That suggests a new dietary paradigm with mixed concepts including several sources with declared content of omega-3 FA for reducing the cardiovascular risk and other acknowledged indications.

3. Debate: Severely Handicapped Newborns: For Sometimes Letting—and Helping—Die

It is often said that all human life, irrespective of its quality or kind, is equally valuable and that our life-and-death decisions for seriously ill or handicapped infants must not be based on the quality or kind of life in question. As the Protestant theologian Paul Ramsey has put it:

The view that all human life—irrespective of its quality or kind—has equal worth may well be the simplest answer to the difficult issues raised about the treatment of infants born seriously ill or with major handicaps; but there are two questions that need to be asked about this simple answer.

TICACOS international: A multi-center, randomized, prospective controlled study comparing tight calorie control versus Liberal calorie administration study

Since the first TICACOS study, 3 additional studies have been published comparing a medical nutrition therapy guided by indirect calorimetry to a regimen prescribed on the basis of predictive equations. A recent guidelines document included a meta-analysis including these 4 papers and found a trend for improvement (OR 0.98-1.48) in favor of medical nutrition therapy guided by indirect calorimetry in terms of survival. The aim of our study was to perform a multicenter prospective, randomized, controlled non blinded study in critically patients to assess the added value for measuring daily resting energy expenditure as a guide for nutritional support. The primary objective was to decrease infectious rate of these critically ill patients.

MATERIAL AND METHODS

This phase III, multi-center, randomized, controlled non blinded study was planned to include 580 newly-admitted, adult ventilated ICU patients that were planned to stay more than 48 h in the ICU departments. The nutritional support was aimed to meet 80-100% of energy requirement measured by indirect calorimetry. The calorie needs were determined by IC in the Study group and by an equation (20-25 kcal/kg ideal body weight/day) in the Control Group. The ICU staff was trained to strive to supply 80-100% of a patient's energy requirements through artificial nutrition, preferably enteral feeding. Primary endpoint was infection rate and secondary endpoints included other morbidities and mortality during ICU, at 90 and 180 days. Comparison between the study and the control group was performed using T test for equality of means (independent samples test). Correlations were performed using the Pearson correlation test. A p level of 0.05 or below was considered as significant. Cross tabs procedure used Chi-square test for testing differences in complication rates, length of stay and length of ventilation. Correlations between energy balances and complications was also be tested using one way analysis as well as ANOVA analysis between groups and within groups. Kaplan Meir curves assessed the proportion of surviving patients in the 2 groups.

RESULTS

Seven centers with a calorimeter available participated to the study. Due to slow inclusion rate, the study was stopped after 6 years and after inclusion of 417 patients only. From the 417 intended to treat patients, 339 followed the protocol. There was no differences between control and study groups in terms of age, sex BMI, SOFA (7.1 ± 3.1 vs 7.4 ± 3.3) and APACHE II scores (22.4 ± 7.9 vs 22.2 ± 7.4). The rate of infection (40 vs 31), including pneumonia rate, need for surgery, dialysis requirement, length of ventilation, ICU length of stay, and hospital length of stay were not different between groups. Mortality (30 in the control vs 21 in the study group) was not significantly different between groups. The decreased mortality observed in the study group when added to previous studies may have a positive effect on the meta-analysis previously published.

CONCLUSION

Tight Calorie Control guided by indirect calorimetry decreased the rate of infection and mortality but not significantly. This may be explained by the not relatively small sample size. There results together with the previous 4 prospective randomized studies, may improve the results of the meta-analysis exploring the effects of IC guided nutrition on mortality.

Reducing the knowledge to action gap in hospital nutrition care - Developing and implementing nutritionDay 2.0

BACKGROUND & AIMS

In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care.

METHODS

We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafés and individual expert feedback involving international health care professionals, nutrition care scientists and patients.

RESULTS

The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap.

CONCLUSION

In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback.

TRIAL REGISTRATION

Registration in clinicaltrials.gov: Identifier: NCT02820246.

Do ethics classes influence student behavior? Case study: Teaching the ethics of eating meat

Do university ethics classes influence students' real-world moral choices? We aimed to conduct the first controlled study of the effects of ordinary philosophical ethics classes on real-world moral choices, using non-self-report, non-laboratory behavior as the dependent measure. We assigned 1332 students in four large philosophy classes to either an experimental group on the ethics of eating meat or a control group on the ethics of charitable giving. Students in each group read a philosophy article on their assigned topic and optionally viewed a related video, then met with teaching assistants for 50-minute group discussion sections. They expressed their opinions about meat ethics and charitable giving in a follow-up questionnaire (1032 respondents after exclusions). We obtained 13,642 food purchase receipts from campus restaurants for 495 of the students, before and after the intervention. Purchase of meat products declined in the experimental group (52% of purchases of at least $4.99 contained meat before the intervention, compared to 45% after) but remained the same in the control group (52% both before and after). Ethical opinion also differed, with 43% of students in the experimental group agreeing that eating the meat of factory farmed animals is unethical compared to 29% in the control group. We also attempted to measure food choice using vouchers, but voucher redemption rates were low and no effect was statistically detectable. It remains unclear what aspect of instruction influenced behavior.

Pandemic ethics: the case for risky research

There is too much that we do not know about COVID-19. The longer we take to find it out, the more lives will be lost. In this paper, we will defend a principle of risk parity: if it is permissible to expose some members of society (e.g. health workers or the economically vulnerable) to a certain level of ex ante risk in order to minimize overall harm from the virus, then it is permissible to expose fully informed volunteers to a comparable level of risk in the context of promising research into the virus. We apply this principle to three examples of risky research: skipping animal trials for promising treatments, human challenge trials to speed up vaccine development, and low-dose controlled infection or “variolation.” We conclude that if volunteers, fully informed about the risks, are willing to help fight the pandemic by aiding promising research, there are strong moral reasons to gratefully accept their help. To refuse it would implicitly subject others to still graver risks.

The ethics of the Global Kidney Exchange programme

The Global Kidney Exchange (GKE) programme seeks to facilitate kidney transplants by matching donor-recipient pairs across high-income, medium-income, and low-income countries. The GKE programme pays the medical expenses of people in medium-income and low-income countries, thus enabling them to receive a kidney transplantation they otherwise could not afford. In doing so, the programme increases the global donor pool, and so benefits people in high-income countries by improving their chances of finding a donor match. Nevertheless, the GKE has been accused of being a form of organ trafficking, exploiting the poor, and involving coercion and commodification of donors. We refute these claims, arguing that the GKE promotes global justice and reduces the potential for people in need of kidneys in low-income and medium-income countries to be exploited. Misguided objections should not be allowed to prevent the GKE from realising its potential to reduce suffering and save the lives of rich and poor patients alike.

Chronic non-bacterial osteomyelitis: a comparative study between children and adults

BACKGROUND

To compare clinical presentation, diagnostic and treatment strategies, and outcome between pediatric and adult patients with chronic non-bacterial osteomyelitis (CNO).

METHODS

Retrospective single-centre comparative study of pediatric and adult patients diagnosed with chronic recurrent multifocal osteomyelitis (CRMO)/CNO or synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome treated at the Medical University of Graz.

RESULTS

24 pediatric patients diagnosed with CRMO/CNO and 10 adult patients diagnosed with SAPHO syndrome were compared. Median age at diagnosis was 12.3 years (range 7.9-18.9) in the pediatric group and 32.5 years (range 22-56) in the adult group. Median time to diagnosis was shorter in children than in adults (0.3 vs. 1.0 years). Initial clinical presentation, laboratory and histopathological findings were similar in children and adults. Mean numbers of bone lesions were comparable between pediatric and adult patients (3.1 vs. 3.0), as were rates of skin involvement (33% vs. 30%). Sternal involvement was more frequent in adults whereas involvement of clavicle and long bones was more frequent in children (41.7% vs.10, 33% vs. 10%). Computerized tomography (CT) was used more often in adults, whereas whole-body magnetic resonance imaging (MRI) was used only in children. Bisphosphonates were applied more often in children and outcome was better in children than in adults (62.5% vs.30%).

CONCLUSION

Results of our study suggest that CNO/CRMO and SAPHO syndrome in children and adults might represent a single clinical syndrome that needs a similar diagnostic and therapeutic approach.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Validation of carbon dioxide production (VCO2) as a tool to calculate resting energy expenditure (REE) in mechanically ventilated critically ill patients: a retrospective observational study

BACKGROUND

Indirect calorimetry (IC) measurement is considered the gold standard for the assessment of resting energy expenditure (REE). It is based on the measurement of oxygen and carbon dioxide consumption (VO2 and VCO2, respectively). However, its use is limited by cost and technical issues. It has been proposed that, in critically ill patients, the analysis of VCO2 obtained from the ventilator alone may be used as an accurate method to assess REE in ventilated patients. This retrospective study aimed to assess the accuracy of VCO2 measurement alone in the determination of REE.

METHODS

This was a retrospective study conducted at the general intensive care unit of a single university-affiliated tertiary medical center. Patients included were invasively ventilated and their REE was measured by using IC. The respiratory quotients (RQs) were set at 0.8, 0.85, and 0.89. Data were collected from computerized patient files. REE obtained from the ventilator by using VCO2 (REE-VCO2) alone was compared with REE obtained from IC (REE-IC).

RESULTS

Measurements were obtained for 80 patients, and 497 REE-IC measurements were compared with REE-VCO2 obtained at the same time. The mean REE-IC was 2059.5 ± 491.7 kcal/d. The mean REE-RQs corresponding to RQs of 0.80, 0.85, and 0.89 were 1936.8 ± 680.0, 2017.8 ± 708.8, and 2122.1 ± 745.4 kcal/d, respectively. REE-VCO2 derived from an RQ of 0.85 had the lowest mean difference from REE-IC. Whereas accuracy was higher using an RQ of 0.85, agreement (between 85% and 115%) was highest using an RQ of 0.89.

CONCLUSIONS

The level of agreement of REE obtained from VCO2 readings with REE obtained from IC was generally low. IC continues to be the recommended method for REE assessment.

Randomised clinical trial: 2% taurolidine versus 0.9% saline locking in patients on home parenteral nutrition

BACKGROUND

The catheter lock solutions 2% taurolidine and 0.9% saline are both used to prevent catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition patients.

AIMS

To compare the effectiveness and safety of taurolidine and saline.

METHODS

This multicentre double-blinded trial randomly assigned home parenteral nutrition patients to use either 2% taurolidine or 0.9% saline for 1 year. Patients were stratified in a new catheter group and a pre-existing catheter group. Primary outcome was the rate of CRBSIs/1000 catheter days in the new catheter group and pre-existing catheter group, separately.

RESULTS

We randomised 105 patients, of which 102 were analysed as modified intention-to-treat population. In the new catheter group, rates of CRBSIs/1000 catheter days were 0.29 and 1.49 in the taurolidine and saline arm respectively (relative risk, 0.20; 95% CI, 0.04-0.71; P = 0.009). In the pre-existing catheter group, rates of CRBSIs/1000 catheter days were 0.39 and 1.32 in the taurolidine and saline arm respectively (relative risk, 0.30; 95% CI, 0.03-1.82; P = 0.25). Excluding one outlier patient in the taurolidine arm, mean costs per patient were $1865 for taurolidine and $4454 for saline (P = 0.03). Drug-related adverse events were rare and generally mild.

CONCLUSIONS

In the new catheter group, taurolidine showed a clear decrease in CRBSI rate. In the pre-existing catheter group, no superiority of taurolidine could be demonstrated, most likely due to underpowering. Overall, taurolidine reduced the risk for CRBSIs by more than four times. Given its favourable safety and cost profile, taurolidine locking should be considered as an additional strategy to prevent CRBSIs.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT01826526.

Viability Test Device for anisakid nematodes

Up to now the visual inspection of mobility of isolated anisakid larvae serves as a measure of viability and possible risk of infection. This paper presents a new method to rule out unreliability – caused by the temporary immobility of the larvae and by the human uncertainty factor of visual observation. By means of a Near infrared (NIR) imaging method, elastic curvature energies and geometric shape parameters were determined from contours, and used as a measure of viability. It was based on the modelling of larvae as a cylindrical membrane system. The interaction between curvatures, contraction of the longitudinal muscles, and inner pressure enabled the derivation of viability from stationary form data. From series of spectrally signed images within a narrow wavelength range, curvature data of the larvae were determined. Possible mobility of larvae was taken into account in statistical error variables. Experiments on individual living larvae, long-term observations of Anisakis larvae, and comparative studies of the staining method and the VTD measurements of larvae from the tissue of products confirmed the effectiveness of this method. The VTD differentiated clearly between live and dead nematode larvae isolated from marinated, deep-frozen and salted products. The VTD has been proven as excellent method to detect living anisakid nematode larvae in fishery products and is seen as useful tool for fish processing industry and control authorities.