Salt and water in nutritional support

Twenty patients with palmo-plantar pustulosis (10 males and 10 females) with a mean age of 41 +/- 6.4 years were compared to 20 controls (10 males and 10 females, mean age 42 +/- 7.2 years, for possible risk factors for palmo-plantar pustulosis. No statistically significant difference was found when the two groups were compared as regards history of atopy diabetes mellitus and thyroid disease. A statistically significant difference was found with regard to cigarette smoking (P < 0.001) and presence of joint symptoms (P < 0.01). This pattern, with minor variations, is similar to the findings in Western countries. There is a need for increased awareness of this association in developing countries. A larger population based study will be highly desirable.     

Specialized nutritional support in respiratory disease

Nutritional status in patients with respiratory disease is discussed and nutritional support and pharmacotherapy considerations in these patients are reviewed. Undernutrition is common among patients with respiratory disease and can lead to decreased respiratory muscle mass and ventilatory drive. Both overfeeding and underfeeding can adversely affect patient outcome. Specialized nutrition-support regimens for patients with respiratory disease should include carbohydrate doses below the maximal oxidative rates for glucose and fat emulsion as a daily continuous infusion. Early enteral feeding may be beneficial. Respiratory quotient, oxygen consumption, and carbon dioxide production are useful measurements in providing optimal nutrition support. Pharmacotherapeutic measures, such as gastrointestinal-tract decontamination and growth-hormone administration, are being investigated in these patients as adjunctive therapy. Nutrition-support regimens for patients with respiratory disease should be carefully designed and monitored to avoid further compromising respiratory function and to reduce the risk of infection.     

Enteral nutritional support in burn patients

Early and continued nutritional support has been determined to be an important component of therapy for seriously burned patients. The hypermetabolic response to severe injury requires increased calorie and protein intake to blunt the catabolism and loss of lean muscle mass. Enteral feeding has been found to directly nourish the gastrointestinal tract and may help reverse the defective gut barrier which accompanies burn shock. In contrast, intravenous nutritional support appears to lack effectiveness in burn patients and may actually increase morbidity and mortality.     

Clinical approaches to nutritional support in cancer

Anorexia and weight loss are frequent complications of cancer and AIDS. Assessment of dietary records and nutritional requirements in patients with decreased food intake and weight loss will assist the dietitian, nurse, or physician in initially addressing the problem. Patients may respond well to nutritional counseling and food supplements, but persistent severe anorexia is common. Various pharmacologic strategies to reverse anorexia and weight loss have been tested, including corticosteroids, anabolic steroids, cyproheptadine, hydrazine sulfate, dronabinol, and megestrol acetate. Dronabinol was recently found to improve appetite in AIDS patients. Megestrol acetate is so far the only agent associated with improvements in appetite and weight in patients with cancer and AIDS. Enteral and parenteral nutrition may be helpful in selected patients with gastrointestinal obstruction or dysfunction, but it is not generally indicated in patients with end-stage disease.     

Assessing the efficacy of nutritional support

This review outlines the conventional methods of assessing nutritional status and their limitations in the presence of acute trauma and sepsis. It also discusses the problems of attempting to improve or at least maintain nutritional status in the presence of an inflammatory stimulus. Most of the conventional markers of nutritional status are altered in trauma and sepsis with decreases in plasma protein concentrations and muscle strength, an apparent depression of immune function and an increase in extracellular fluid volume. It also appears to be impossible to improve nutritional status in the presence of a severe inflammatory stimulus, and the most one can hope for is to attenuate the rate of decline. The evidence for these observations is discussed.     

Hospital-made diet versus commercial supplement in postburn nutritional support

Nutritional support is an important aspect of the management of burn patients. Nutrition supplementation can be achieved either by 'hospital-made' or 'commercial' diets. Commercial diets are efficacious but expensive and sometimes not easily available. This study was undertaken to compare the efficacy and tolerance of a hospital-made diet with a commercial diet. Twenty patients with burns ranging from 20-50 per cent TBSA were studied to compare the efficacy and tolerance of the 'hospital-made' diet with 'commercial' preparations. Patients were divided into two groups of 10 each and randomised within each group to receive either a hospital-made diet (five patients) or a commercial diet (five patients). Efficacy of diet was assessed by evaluation of nutritional status, graft take, number of surgical procedures and duration of hospital stay. Tolerance was assessed by recording side effects such as nausea, vomiting, abdominal distention and diarrhoea. Both diets were well tolerated by all patients. There was no significant difference in nutritional status, number of surgical procedures, percentage of graft take and duration of hospital stay on either diet, suggesting that hospital-made diets are similar in efficacy and tolerance but cheaper and more easily available. They are a good alternative to 'commercial' diets, especially in poor patients.     

A comparison of general practice in Britain and Ireland

The work patterns of general practitioners in the British NHS and in the General Medical Services Scheme in the Republic of Ireland are compared. Doctors in the Republic have higher consultation and domiciliary visiting rates. These differences are not explainable in terms of the different age/sex structures of the populations under care.     

Gastrostomy buttons for nutritional support on chronic dialysis

RATIONALE: Nutritional support for children on chronic dialysis often involves the use of nasogastric tubes or gastrostomy feeding. We report our experience using gastrostomy buttons (GB) over a 6.6-year period to document their success/failure, the feeding regimens employed and the impact on growth. DESIGN: In 339 patient months of prospective observation, 22 children (14 male) commenced gastrostomy feeding at a median age of 2.3 years (range 0.2-10.3 years). Sixteen patients had an initial gastrostomy catheter inserted at the same time as a chronic dialysis catheter. Eighteen patients were established on continuous cycling peritoneal dialysis (CCPD) and four on haemodialysis (HD). RESULTS: The mean duration of combined gastrostomy feeding and chronic dialysis was 14.5 months (range 2.4 56 months). In 20 of the children followed for 6 months on combined GB feeding and dialysis, the mean protein and energy intakes were 2.5 g/kg bodyweight/day (range 1.7-3.4 g) and 108 kcal/kg bodyweight/day (range 72-129 kcal). The mean energy intake achieved was 116% (range 98-155%) of the estimated average requirement (EAR) for energy. The mean percentage of total energy and protein intakes delivered via the GB during the study period was 61% (33-95%) and 61% (23-98%) respectively. Mean height standard deviation score (SDS) was -2.22 prior to GB feeding and -2.06 at the end of the study period (P = 0.005) and mean weight SDS was -2.22 and -1.16 (P = 0.001) respectively. The mean life of the GB was 7.7 months (range 2.6 14 months) with most button changes due to leakage problems. Two episodes of peritonitis were attributable to the GB with one requiring peritoneal dialysis catheter removal due to candida infection. The GB was removed at a mean of 2.8 months (range 0.8-8.3 months) after renal transplantation in 13 children. CONCLUSION: The gastrostomy button provides a valuable and aesthetically appealing route for nutritional support with few complications.     

Evolution of the nutritional support pattern in pediatric intensive care

OBJECTIVES: To evaluate patterns of usage and monitoring of nutritional support in a Pediatric ICU of a teaching hospital and the role of an education program in nutritional support given throughout the resident physician training. DESIGN: In a historical cohort study, records from children who received nutritional support during the year 1992 were analyzed. Thereafter a continuing education program in Nutritional Support was conveyed to the residents. In a second phase of the study, the same parameters were reevaluated in children who received nutritional support throughout the year 1995. SETTING: Pediatric Intensive Care Unit of Department of Pediatrics, Escola Paulista de Medicina. PATIENTS: All the children who were given nutritional support during a period of five days or more. Based on this criteria 37 children were selected for the first phase of this study, and 35 for the second one. INTERVENTION: The education program included theoretical lectures about basic themes of nutritional support and journal article reading sessions. It was given to successive groups of residents on a weekly schedule. MEASUREMENTS: Daily records of fluid, protein, caloric and micronutrient supply, nutritional assessment and metabolic monitoring. RESULTS: In the first phase of the study, an exclusively parenteral route was utilized for 80.5%, and a digestive route 19.5% of the time period. Nutritional assessment was performed on 3 children; no patient had the nutritional goals set. The nitrogen to nonprotein calories ratio and the vitamin supply were inadequate, whilst the supply of trace elements was adequate except for zinc. Nutritional monitoring was performed on almost all patients but without uniformity. In the second phase, the exclusive parenteral route was used for 69.7% and the digestive route for 30.3% of the time period; no significant increase in the use of the digestive route was detected. The nonprotein calories to nitrogen ratio and micronutrient supply were adequate. The frequency of nutritional assessment increased, but deficiency in nutritional monitoring and infrequent enteral feeding were still detected. CONCLUSION: There were deficiencies in the implementation of nutritional support, which were partially corrected in the second phase of the study by the training of the residents. Reinforcement of the education program, which should be applied to the whole medical staff, and the organization of a multidisciplinary team in charge of coordinating the provision of nutritional support are suggested.     

Mental illness in India and Britain: theory and practice

The paper argues that conceptions of mental illness and its treatment often stem from the normative social and cultural constructions of mental illness. Psychiatrists, psychologists, and other health professionals do not work in a social vacuum; they work within the accepted traditions and values prevalent in their culture. To understand mental illness it is therefore necessary to examine the salient normative beliefs, attitudes, and values of a given culture. The paper proposes a cross-cultural theoretical and empirical model which permits a close examination and comparison of mental illness in two cultures: India and Britain. The proposed model from which several testable hypotheses have been deduced, rests on the following four factors; [Table See Text]. The nature and the importance of the factors in explaining mental illness and the culture-specific treatment strategies which follow in the two cultures are critically discussed in the paper.     

Triangulation in clinical practice

The aim of the article is to clarify the research term 'triangulation'. Examples are given to illustrate the use of triangulation in clinical practice. The strength of using triangulation in both the design and analysis stages are highlighted.     

Immunomodulators in clinical practice

Immunomodulators have opened new vistas in the management of the immunocompromised patient. They have been shown to enhance the efficacy of vaccines in infections, head and neck malignancy, the immunosuppressed and recently in AIDS. The mechanism of their action is discussed. They hold promise of further advances in immunotherapy.     

Noonan syndrome in clinical practice

The author presents the basic criteria for clinical recognition of Noonan syndrome. The hypothetical pathogenesis, differential diagnosis and risk of recurrence of this syndrome are also discussed.     

Study environment in clinical practice

Ultrasound treatment of the surface of festered wounds and application on them of specific heteroplasma were used in 46 patients for healing of festered wounds. The method provides broadening of the indication for application of primary suture on the festered wound and decrease of the duration of hospital stay of the patients 2.2 fold.     

Electroconvulsive therapy in clinical practice

Using electron-beam computed tomography (EBCT) with short exposure times of 100 or 50 ms and the capability of acquiring up to 2 x 17 images/s it is possible to study most of the important morphological and functional determinants of the heart. Various examples of studies in acute and chronic cardiac diseases are shown to demonstrate the use of EBCT to determine quantitatively left ventricular volumes (ml), myocardial mass (g), wall thickness changes over the cardiac cycle (mm/s), myocardial perfusion (ml/ 100 g/min) and the extent of coronary calcification (calcium score) and qualitatively the state of the proximal 4-6 cm of the subepicardial coronary arteries. The knowledge of these determinants seems very useful in excluding cardiac dysfunction, in the early recognition of cardiac disease and in the evaluation of the haemodynamic severity of coronary artery stenotic lesions. Further interdisciplinary studies are necessary to assess the clinical validity of these cardiac determinants, especially myocardial perfusion, using this advanced CT technology.     

Adherence issues in clinical practice

The reproducibility of short tandem repeat (STR) amplification of aDNA extracts is limited by means of formation of artifacts during PCR. One of these artifacts, the so called allelic-dropout (failure of the amplification of alleles), may result in false-homozygote typing of a sample, if genotyping is based on the analysis of a single amplification product. 30 tooth- and bone samples collected from 17 individuals of three burial sites were investigated in a blind test. Using the polymerase chain reaction (PCR) the two independent segregating STR-loci HUMVWA and HUMTH01 were amplified. Corresponding to a mathematical estimation, multiple amplifications of each sample and genelocus were carried out. The results of this genotyping were compared intraindividually.     

Good clinical practice

Nine new phenylpropanoids (2-7, 10, 12, and 14) and two compounds representing novel structural classes of 7-O-8' and 7-O-8'.8-O-7' lignans (8 and 9, respectively) have been isolated from Illicium verum and their structures established by two-dimensional NMR. Most of these compounds appear to be biogenetically derived from threo-anethole glycol: relative stereochemistries for some members of this series were established by NOESY; absolute stereochemistries of others were determined by formation of Mosher esters.