Enhanced recovery of patients after surgery (“ERAS”) has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care ...include:
•
avoidance of long periods of pre-operative fasting;
•
re-establishment of oral feeding as early as possible after surgery;
•
integration of nutrition into the overall management of the patient;
•
metabolic control, e.g. of blood glucose;
•
reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function;
•
early mobilisation
Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference.
EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10–15% within 6 months, BMI<18.5
kg/m
2, Subjective Global Assessment Grade C, serum albumin <30
g/l (with no evidence of hepatic or renal dysfunction).
Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.
The full version of this article is available at
www.espen.org.
Does procalcitonin (PCT) differentiate between infection and rejection after liver transplantation in patients with fever of unknown origin?
Open prospective trial.
Transplant intensive care unit at ...a university hospital.
Forty patients after liver transplantation.
Liver biopsy for the diagnosis of rejection and transcutaneous aspiration cytology for monitoring of lymphocyte activation.
Procalcitonin from EDTA plasma, Acute Physiology and Chronic Health Evaluation II, and sepsis score.
Eleven patients experienced an infectious complication resulting in an increase in PCT concentrations (2.2-41.7 ng/mL). Eleven patients had a rejection episode; none of these patients showed a rise in PCT concentrations. The statistical difference between PCT concentrations in rejection and infection was significant (p<.05) on the day of diagnosis.
PCT allows for differentiation between rejection and infection in patients with fever of unknown origin. Elevation of PCT plasma concentrations develops early postoperatively from operation trauma, and in the case of fever of unknown origin, with no rise in PCT, a rejection may be suspected.
This talk presents bandwidth enhancement technique of axial ratio (AR) in 1 -point-fed circularly polarized (CP) microstrip antennas using metasurface (MS). In these structures, MSs consisting of a ...rectangular unit cell have been used for widening the impedance bandwidth in addition to the AR bandwidth. The author called this structure artificial ground structure (AGS) for the dual purpose. The AGS has been installed underneath the patch antenna with two truncated corners, and the substrates have a relative permittivity of ε r = 2.2 and loss tangent of tan δ = 0.001 (ROGERS RT/Duroid 5880). The AGS has the function of an AMC for expanding the -10-dB S 11 bandwidth. Also, the AGS can convert the incident wave of linear polarization (LP) or elliptical polarization (EP) to CP reflected wave. This mechanism can extend the AR bandwidth. However, this expansion is sometimes limited by resonances in related to the outer circumference of the MS structure. If the circumference is rectangular, that is the dimension along x is different from that along y, an extra difference of phase causes in x- and y- components of the radiated field resulting in deteriorated AR.
A major thrust of transplantation research is to find more effective and less broadly toxic immunosuppressive agents. One potential way is the use of monoclonal antibodies directed to IL‐2Rα.
...Immunoprophylaxis with daclizumab, a humanized anti‐IL‐2Rα monoclonal antibody, has been shown to be effective in the prevention of acute rejection in kidney transplant patients.
These results encouraged us to initiate a pilot study in 28 liver transplant patients in 1997.
Daclizumab was administered intravenously approximately 6 h after reperfusion (1 mg/kg) and on day 4 post‐transplant (0.5 mg/kg). Additional immunosuppression consisted of cyclosporine A as well as of corticosteroids.
Administration of daclizumab was not associated with any side‐effects. We only experienced one acute rejection in a patient on day 17 post‐transplant. It resolved immediately under therapy with prednisolone. The rate of opportunistic infections did not differ from results with conventional immunosuppressive regimens. At 4 years post‐transplant no lymphoproliferative disease was observed. Patient survival at 12, 24, 36 and 48 months post‐transplant was 88.5, 84.6, 80.8 and 73.1%, respectively.
Immunoprophylaxis with a two‐dose daclizumab regimen is safe, effective and well tolerated, and does not lead to increased opportunistic infections.
ABSTRACT Precision agriculture adoption in Brazilian apple orchards is still incipient. This study aimed at evaluating the spatial variability of certain soil properties as soil density, soil ...penetration resistance, electrical conductivity, yield, and fruit quality in an apple orchard through digital mapping, as well as assessing the correlation between these factors by means of geostatistics, establishing management zones. Forty representative points were set within 2.5 hectares of apple orchard, wherein soil samples were collected and analyzed, besides measurements of fruit quality (Brix degree, size or diameter, pulp firmness and color) to generate an overall index quality. We concluded that the fruit quality indexes, when isolated, did not show strong spatial dependence, unlike the index of fruit quality (FQI), derived from a combination of these parameters, allowing orchard planning according to management zones based on quality.
The optimum treatment conditions of interferon (IFN) alpha therapy in chronic myeloid leukemia (CML) are still controversial. To evaluate the role of hydroxyurea (HU) for the outcome of IFN therapy, ...we conducted a randomized trial to compare the combination of IFN and HU vs HU monotherapy (CML-study II). From February 1991 to December 1994, 376 patients with newly diagnosed CML in chronic phase were randomized. In all, 340 patients were Ph/BCR-ABL positive and evaluable. Randomization was unbalanced 1:2 in favor of the combination therapy, since study conditions were identical to the previous CML-study I and it had been planned in advance to add the HU patients of study I (n=194) to the HU control group. Therefore, a total of 534 patients were evaluable (226 patients with IFN/HU and 308 patients with HU). Analyses were according to intention-to-treat. Median observation time of nontransplanted living patients was 7.6 years (7.9 years for IFN/HU and 7.3 years for HU). The risk profile (new CML score) was available for 532 patients: 200 patients (38%) were low, 239 patients (45%) intermediate, and 93 patients (17%) high risk. Complete hematologic response rates were higher in IFN/HU-treated patients (59 vs 32%). Of 169 evaluable IFN/HU-treated patients (75%), 104 patients (62%) achieved a cytogenetic response that was complete in 12% (n=21), major in 14% (n=24), and at least minimal in 35% (n=59). Of the 534 patients, 105 (20%) underwent allogeneic stem cell transplantation in first chronic phase. In the low-risk group, 65 of 200 patients were transplanted (33%), 30 (13%) in the intermediate-risk group, and nine (10%) in the high-risk group. Duration of chronic phase was 55 months for IFN/HU and 41 months for HU (P<0.0001). Median survival was 64 months for IFN/HU and 53 months for HU-treated patients (P=0.0063). We conclude that IFN in combination with HU achieves a significant long-term survival advantage over HU monotherapy. In view of the data of CML-study I, these results suggest that IFN/HU is also superior to IFN alone. HU should be combined with IFN in IFN-based therapies and for comparisons with new therapies.
Summary Background Invasive candidosis is increasingly prevalent in seriously ill patients. Our aim was to compare micafungin with liposomal amphotericin B for the treatment of adult patients with ...candidaemia or invasive candidosis. Methods We did a double-blind, randomised, multinational non-inferiority study to compare micafungin (100 mg/day) with liposomal amphotericin B (3 mg/kg per day) as first-line treatment of candidaemia and invasive candidosis. The primary endpoint was treatment success, defined as both a clinical and a mycological response at the end of treatment. Primary analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov , number NCT00106288. Findings 264 individuals were randomly assigned to treatment with micafungin; 267 were randomly assigned to receive liposomal amphotericin B. 202 individuals in the micafungin group and 190 in the liposomal amphotericin B group were included in the per-protocol analyses. Treatment success was observed for 181 (89·6%) patients treated with micafungin and 170 (89·5%) patients treated with liposomal amphotericin B. The difference in proportions, after stratification by neutropenic status at baseline, was 0·7% (95% CI −5·3 to 6·7). Efficacy was independent of the Candida spp and primary site of infection, as well as neutropenic status, APACHE II score, and whether a catheter was removed or replaced during the study. There were fewer treatment-related adverse events—including those that were serious or led to treatment discontinuation—with micafungin than there were with liposomal amphotericin B. Interpretation Micafungin was as effective as—and caused fewer adverse events than—liposomal amphotericin B as first-line treatment of candidaemia and invasive candidosis.
BACKGROUND: Experimental studies have revealed that gelatin and HES produce increased neutrophil respiratory burst activity. It was investigated whether 3‐percent gelatin (MW 35,000) and three types ...of 6‐percent HES (MW 70,000; degree of substitution, 0.5; 200,000/0.5; 450,000/0.7) preparations can influence superoxide anion production during respiratory burst under clinical conditions.
STUDY DESIGN AND METHODS: Blood samples were obtained from 40 patients before and 1 hour after the infusion, before anesthesia and surgical treatment. After stimulation with bacteria (Escherichia coli), the respiratory burst was measured by oxidation of nonfluorescent dihydrorhodamine 123 to the fluorescent rhodamine 123 by the use of flow cytometry.
RESULTS: Respiratory burst activity decreased significantly (p = 0.004) from the baseline (60.0 ± 6.5%) to 1 hour after the administration of the low‐molecular‐weight HES preparation (55.0 ± 6.8%). No significant differences in respiratory burst activity could be found after the administration of gelatin or medium‐molecular‐weight or high‐ molecular‐weight HES solution.
CONCLUSION: The investigated administration of gelatin and medium‐ and high‐molecular‐weight HES preparations did not influence respiratory burst activity under clinical conditions. However, the neutrophil respiratory burst was impaired after the administration of low‐molecular‐weight HES. Neutrophil respiratory burst activity may vary according to the type of colloidal plasma substitutes administered.
Mycoplasma hominis has been recognized as an extragenital pathogen in immunocompromised hosts, including kidney and heart transplant recipients; patients with systemic autoimmune diseases, lymphomas, ...or leukemia; and patients who have undergone cardiac surgery or who have experienced trauma. Liver transplantation has rarely been reported to increase host susceptibility to intraabdominal M. hominis infection. We describe two liver transplant recipients with extragenital M. hominis infection, and we emphasize the need for physicians to be aware of the pathogenicity of M. hominis for this group of patients. The isolation of M. hominis from the pleural space and the abdominal surgical wound in the first case and from an intrahepatic abscess in the second one indicates that M. hominis infection in sites other than the peritoneal cavity should be considered. We furthermore propose the use of sequence determination of the tuf gene for rapid species diagnosis to accelerate clinical decisions.
We evaluated toxicity, engraftment, chimerism, graft-versus-host disease (GVHD), and response to a dose-reduced allograft after cytoreductive autografting in 17 patients with advanced stage II/III ...multiple myeloma (MM). After autografting with melphalan (200 mg/m2) the patients received after a median interval of 119 days (range 60-210) a dose-reduced regimen consisting of fludarabine (180 mg/m2), melphalan (100 mg/m2), and antithymocyte globulin (3 × 10 mg/kg) followed by allografting from related (n = 7), mismatched related (n = 2), or unrelated (n = 8) donors to induce a graft-versus-myeloma effect. After dose-reduced allografting all patients became neutropenic (< 0.2 × 109/L) for at least 8 days. All patients engrafted with a median time for leukocyte (> 1 × 109/L) and platelet (> 20 × 109/L) counts of 16 (range, 11-24) and 23 days (range, 12-43), respectively. Complete donor chimerism was detected after a median of 30 days (range, 19-38). Acute GVHD stage II occurred in 4 patients (25%) and grade III GVHD in 2 patients (13%). Chronic GVHD developed in 40% of the patients, but only 1 patient experienced extensive chronic GVHD requiring further immunosuppressive therapy. Two patients died of alveolar hemorrhage and pneumonia, resulting in a day 100 mortality rate of 11%. The rate of complete remission with negative immunofixation increased from 18% after autografting to 73% after allografting. After a median follow-up of 17 months after autologous and 13 months after allogeneic transplantation 13 patients are alive and 12 of them free of relapse or progression. The tandem auto-allotransplant protocol is highly active and provides rapid engraftment with complete donor chimerism and tolerable toxicity.
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