A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice.

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4-7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

Mechanistic Insights into the CO2 Methanation Catalyzed by Supported Metals: A Review.

The production of methane from the reaction between CO2 and H2 (CO2 methanation) has gained increasing attention in recent years. The rational design of novel catalytic materials for this reaction will depend on the fundamental description of the active sites and the identification of surface reaction intermediates. Currently, there is a debate regarding the mechanism for the CO2 methanation on supported metals, with apparently contradictory proposals suggesting that various surface species could be either reaction intermediates or spectators. Similarly, there is a discussion regarding the nature of the surface sites on the catalysts that activate the CO2 molecule during the reaction. Specifically, it has been suggested that different reaction routes could occur on different metalsupport combinations and on various surface structures. In this manuscript, we critically review the literature on CO2 methanation and discuss the physical evidence that has been presented to propose reaction mechanisms on various supported metals. The relevance of the presence of nanosized metal particles in the catalysts is also discussed.

Single-sided deafness and cochlear implantation in congenital and acquired hearing loss in children.

OBJECTIVE: To determine the audiological and clinical results of cochlear implantation in children below the age of 12 years old with congenital and acquired single-sided deafness. DESIGN: Observational, descriptive, transversal study. MAIN OUTCOME MEASURES: Speech reception thresholds, Cortical responses, Auditory Lateralization Test and SSQ questionnaire. PARTICIPANTS: Children < 12 implanted for congenital or acquired SSD. RESULTS: All the children with congenital SSD showed positive cortical responses. Positive results were obtained in the Auditory Lateralization Test for the following modalities: 0º, 45º and 90º. With respect to the Speech Test, the children with acquired SSD showed the following results: 92% and 100% in recognition and 48% and 68% (Azimuth modalities), Signal CI side 52% and 68% and Signal normal hearing side 44% - 60% (p < 0.05). In both group the processor was used for 6-12 hours. With respect to the SSQ questionnaire results, the parents were more satisfied within the post-operative period than within the pre-operative period (P<0.001). CONCLUSIONS: Cochlear implant provides children with congenital SSD with significant audiological and subjective benefits. Children with congenital SSD and implanted after a longer period may not have an important benefit (binaural) although other bilateral effects can be achieved. Children with post-lingual unilateral deafness and after a short period of hearing deprivation probably integrated the normal acoustic hearing with the cochlear implant electrical signal and showed binaural benefits.

[Diagnostic test scale SI5: Assessment of sacroiliac joint dysfunction]. / Escala de diagnóstico SI5: evaluación de disfunción de la articulación sacroiliaca.

OBJECTIVE: Sacroiliac joint dysfunction is a known cause of low back pain. We think that a diagnostic score scale (SI5) may be performed to assess diagnostic utility of clinical signs of sacroiliac joint dysfunction. The primary aim of the present study was to conduct the pilot study of our new diagnostic score scale, the SI5, for sacroiliac joint syndrome. MATERIAL AND METHODS: We reviewed the literature on clinical characteristics, diagnostic tests and imaging most commonly used in diagnosing sacroiliac joint dysfunction. Our group evaluated the diagnostic utility of these aspects and we used those considered most representative to develop the SI5 diagnostic scale. The SI5 scale was applied to 22 patients with low back pain; afterwards, the standard test for diagnosing this pathology (selective blockage of the SI joint) was also performed on these patients. The sensitivity and specificity for each sign were also assessed and the diagnostic scale called SI5 was then proposed, based on these data. RESULTS: The most sensitive clinical tests for diagnosing SI joint dysfunction were 2 patient-reported clinical characteristics, the Laguerre Test, sacroiliac rocking test and Yeomans test (greater than 80% sensitivity). The tests with greatest diagnostic specificity (>80%) were the Lewitt test, Piedallu test and Gillet test. The proposed SI5 test score scale showed sensitivity of 73% and specificity of 71%. CONCLUSIONS: Sacroiliac joint syndrome has been shown to produce low back pain frequently; however, the diagnostic value of examination tests for sacroiliac joint pain has been questioned by other authors. The pilot study on the SI5 diagnostic score scale showed good sensitivity and specificity. However, the process of statistical validation of the SI5 needs to be continued.

A comparison of continuous video-EEG monitoring and 30-minute EEG in an ICU.

AIM: To determine whether there is added benefit in detecting electrographic abnormalities from 16-24 hours of continuous video-EEG in adult medical/surgical ICU patients, compared to a 30-minute EEG. METHODS: This was a prospectively enroled non-randomized study of 130 consecutive ICU patients for whom EEG was requested. For 117 patients, a 30-minute EEG was requested for altered mental state and/or suspected seizures; 83 patients continued with continuous video-EEG for 16-24 hours and 34 patients had only the 30-minute EEG. For 13 patients with prior seizures, continuous video-EEG was requested and was carried out for 16-24 hours. We gathered EEG data prospectively, and reviewed the medical records retrospectively to assess the impact of continuous video-EEG. RESULTS: A total of 83 continuous video-EEG recordings were performed for 16-24 hours beyond 30 minutes of routine EEG. All were slow, and 34% showed epileptiform findings in the first 30 minutes, including 2% with seizures. Over 16-24 hours, 14% developed new or additional epileptiform abnormalities, including 6% with seizures. In 8%, treatment was changed based on continuous video-EEG. Among the 34 EEGs limited to 30 minutes, almost all were slow and 18% showed epileptiform activity, including 3% with seizures. Among the 13 patients with known seizures, continuous video-EEG was slow in all and 69% had epileptiform abnormalities in the first 30 minutes, including 31% with seizures. An additional 8% developed epileptiform abnormalities over 16-24 hours. In 46%, treatment was changed based on continuous video-EEG. CONCLUSION: This study indicates that if continuous video-EEG is not available, a 30-minute EEG in the ICU has a substantial diagnostic yield and will lead to the detection of the majority of epileptiform abnormalities. In a small percentage of patients, continuous video-EEG will lead to the detection of additional epileptiform abnormalities. In a sub-population, with a history of seizures prior to the initiation of EEG recording, the benefits of continuous video-EEG in monitoring seizure activity and influencing treatment may be greater.

Clinical spectrum of artery of Percheron infarct: clinical-radiological correlations.

BACKGROUND: The occlusion of the artery of Percheron results in bilateral thalamic and mesencephalic infarctions. In this series, we attempted to classify the subtypes of clinical presentations and long-term prognosis with regards to radiological patterns. METHODS: We sought the clinical and radiological findings of 15 (8 men and 7 women; mean age 48 years) consecutive patients with Percheron artery infarct over 10 years. We classified the clinical symptoms according to the presence of a mental status disturbance (MSD), behavioral amnesic impairment (BAI), aphasia/dysarthria, ocular movement disorders (OMDs), motor deficit, cerebellar signs, and others. The Percheron artery infarct images were classified as bilateral paramedian thalamic with rostral midbrain infarction (BPTRMI), bilateral paramedian thalamic without midbrain infarction (BPTWMI), bilateral paramedian and anterior thalamic with midbrain infarction (BPATMI), and bilateral paramedian and anterior thalamic without midbrain infarction. The outcome was evaluated using a modified Rankin Scale (mRS). RESULTS: OMD and MSD were the most common clinical manifestations in patients with BPTRMI (n = 8). BAI and MSD were the main clinical findings in patients with BPTWMI (n = 6). A patient with BPATMI had a combination of clinical manifestations. After a mean follow-up of 55 months, a good outcome (mRS score ≤ 2) was present in 25% of the patients with BPTRMI, 67% of the patients with BPTWMI, and in 1 patient with BPATMI. CONCLUSIONS: Our findings suggest that it is possible to identify clinical and radiological subgroups of Percheron artery infarct. The long-term follow-up outcome is generally good, except in cases with midbrain involvement.

Development of a new low-cost computer vision system for human gait analysis: A case study.

Today, human gait analysis is commonly used for clinical diagnosis, rehabilitation and performance improvement in sports. However, although previous research works in the literature address the use of motion capture systems by means of optoelectronic sensors, Inertial Measurement Units (IMUs) and depth cameras, few of them discuss their conception, guidelines and algorithms for measuring and calculating gait metrics. Moreover, commercially available motion capture systems, although efficient, are cost restrictive for most of the low-income institutions. In this research work, a new computer vision-based system (CVS) for gait analysis is developed and proposed. The aim is to close the gap found in the literature about the design and development of such systems by providing the requirements, considerations, algorithms and methodologies used to develop a gait analysis system with acceptable precision and accuracy, and at low cost. For this purpose, a linear computer vision method based on the non-homogeneous solution of the calibration matrix was used. The spatio-temporal and angular gait parameters were implemented in the proposed system, and compared with those reported in the literature. The denoising of the spatial gait trajectories and the strategies to detect gait events, are also presented and discussed. The results have shown that the proposed system is satisfactory for human gait analysis in terms of precision, computational performance and low cost.

Standardizing an Experimental Murine Model of Extraparenchymal Neurocysticercosis That Immunologically Resembles Human Infection.

BACKGROUND: Neurocysticercosis (NCC) is endemic in non-developed regions of the world. Two forms of NCC have been described, for which neurological morbidity depends on the location of the lesion, which can be either within the cerebral parenchyma or in extraparenchymal spaces. The extraparenchymal form (EXP-NCC) is considered the most severe form of NCC. EXP-NCC often requires several cycles of cysticidal treatment and the concomitant use of glucocorticoids to prevent increased inflammation, which could lead to intracranial hypertension and, in rare cases, to death. Thus, the improvement of EXP-NCC treatment is greatly needed. METHODS: An experimental murine model of EXP-NCC, as an adequate model to evaluate new therapeutic approaches, and the parameters that support it are described. EXP-NCC was established by injecting 30 Taenia crassiceps cysticerci, which are less than 0.5 mm in diameter, into the cisterna magna of male and female Wistar rats. RESULTS: Cyst implantation and infection progression were monitored by detecting the HP10 antigen and anti-cysticercal antibodies in the serum and cerebral spinal fluid (CSF) of infected rats and by magnetic resonance imaging. Higher HP10 levels were observed in CSF than in the sera, as in the case of human EXP-NCC. Low cell recruitment levels were observed surrounding established cysticerci in histological analysis, with a modest increase in GFAP and Iba1 expression in the parenchyma of female animals. Low cellularity in CSF and low levels of C-reactive protein are consistent with a weak inflammatory response to this infection. After 150 days of infection, EXP-NCC is accompanied by reduced levels of mononuclear cell proliferation, resembling the human disease. EXP-NCC does not affect the behavior or general status of the rats. CONCLUSIONS: This model will allow the evaluation of new approaches to control neuroinflammation and immunomodulatory treatments to restore and improve the specific anti-cysticercal immunity in EXP-NCC.

Role of iron carbonyls in the inhibition of oxygen activation for the oxidation of CO catalyzed by iron oxide-supported gold.

Iron oxide-supported gold samples were prepared by co-precipitation from HAuCl(4) and Fe(NO(3))(3). The activities of the samples as CO oxidation catalysts were tested without thermal treatment and following treatments in flows of He and O(2) at various temperatures. It was found that the untreated samples and those treated in a flow of He at 150 °C were more active than samples that had been treated at 400 °C in either a flow of O(2) or of He. Infrared spectra recorded during CO oxidation catalysis indicate the presence of bonded CO molecules to cationic gold on all samples, whereas spectra of the least active catalysts indicate a predominant presence of Fe(2+) carbonyls, which were highly stable under the conditions of our experiments. Our results indicate that in the least active samples the Fe(2+)-bound CO blocks sites that would otherwise be available for oxygen activation.

Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period.

PURPOSES: Emergency physician-performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician-performed ultrasonography for multiple categories of ultrasound use after a short training period. BASIC PROCEDURES: This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation. MAIN FINDINGS: A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained. PRINCIPAL CONCLUSIONS: Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.

Cerebral Hemodynamic Reserve Abnormalities Detected Via Transcranial Doppler Ultrasound in Recovered COVID-19 Patients.

INTRODUCTION: SARS-CoV-2 infection can produce endothelial injury and microvascular damage, one cause of the multiorgan failure associated with COVID-19. Cerebrovascular endothelial damage increases the risk of stroke in COVID-19 patients, which makes prompt diagnosis important. Endothelial dysfunction can be evaluated by using transcranial Doppler ultrasound to study cerebral hemodynamic reserve, but there are few of these studies in patients with COVID-19, and the technique is not included in COVID-19 action and follow-up guidelines nationally or internationally. OBJECTIVE: Estimate baseline cerebral hemodynamic patterns, cerebral hemodynamic reserve, and breath-holding index in recovered COVID-19 patients. METHOD: We conducted an exploratory study in 51 people; 27 men and 24 women 20-78 years of age, divided into two groups. One group comprised 25 recovered COVID-19 patients, following clinical and epidemiological discharge, who suffered differing degrees of disease severity, and who had no neurological symptoms or disease at the time they were incorporated into the study. The second group comprised 26 people who had not been diagnosed with COVID-19 and who tested negative by RT-PCR at the time of study enrollment. Recovered patients were further divided into two groups: those who had been asymptomatic or had mild disease, and those who had severe or critical disease. We performed transcranial Doppler ultrasounds to obtain baseline and post-apnea tests of cerebral hemodynamic patterns to evaluate cerebral hemodynamic reserve and breath-holding indices. We characterized the recovered patient group and the control group through simple descriptive statistics (means and standard deviations). RESULTS: There were no measurable differences in baseline cerebral hemodynamics between the groups. However, cerebral hemodynamic reserve and breath-holding index were lower in those who had COVID-19 than among control participants (19.9% vs. 36.8% and 0.7 vs. 1.2 respectively). These variables were similar for patients who had asymptomatic or mild disease (19.9% vs.19.8%) and for those who had severe or critical disease (0.7 vs. 0.7). CONCLUSIONS: Patients recovered from SARS-CoV-2 infection showed decreased cerebral hemodynamic reserve and breath-holding index regardless of the disease's clinical severity or presence of neurological symptoms. These abnormalities may be associated with endothelial damage caused by COVID-19. It would be useful to include transcranial Doppler ultrasound in evaluation and follow-up protocols for patients with COVID-19.

Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

BACKGROUND & AIMS: The importance of artificial nutritional therapy is underrecognized, typically being considered an adjunctive rather than a primary therapy. We aimed to evaluate the influence of nutritional therapy on mortality in critically ill patients. METHODS: This multicenter prospective observational study included adult patients needing artificial nutritional therapy for >48 h if they stayed in one of 38 participating intensive care units for ≥72 h between April and July 2018. Demographic data, comorbidities, diagnoses, nutritional status and therapy (type and details for ≤14 days), and outcomes were registered in a database. Confounders such as disease severity, patient type (e.g., medical, surgical or trauma), and type and duration of nutritional therapy were also included in a multivariate analysis, and hazard ratios (HRs) and 95% confidence intervals (95%CIs) were reported. RESULTS: We included 639 patients among whom 448 (70.1%) and 191 (29.9%) received enteral and parenteral nutrition, respectively. Mortality was 25.6%, with non-survivors having the following characteristics: older age; more comorbidities; higher Sequential Organ Failure Assessment (SOFA) scores (6.6 ± 3.3 vs 8.4 ± 3.7; P < 0.001); greater nutritional risk (Nutrition Risk in the Critically Ill [NUTRIC] score: 3.8 ± 2.1 vs 5.2 ± 1.7; P < 0.001); more vasopressor requirements (70.4% vs 83.5%; P=0.001); and more renal replacement therapy (12.2% vs 23.2%; P=0.001). Multivariate analysis showed that older age (HR: 1.023; 95% CI: 1.008-1.038; P=0.003), higher SOFA score (HR: 1.096; 95% CI: 1.036-1.160; P=0.001), higher NUTRIC score (HR: 1.136; 95% CI: 1.025-1.259; P=0.015), requiring parenteral nutrition after starting enteral nutrition (HR: 2.368; 95% CI: 1.168-4.798; P=0.017), and a higher mean Kcal/Kg/day intake (HR: 1.057; 95% CI: 1.015-1.101; P=0.008) were associated with mortality. By contrast, a higher mean protein intake protected against mortality (HR: 0.507; 95% CI: 0.263-0.977; P=0.042). CONCLUSIONS: Old age, higher organ failure scores, and greater nutritional risk appear to be associated with higher mortality. Patients who need parenteral nutrition after starting enteral nutrition may represent a high-risk subgroup for mortality due to illness severity and problems receiving appropriate nutritional therapy. Mean calorie and protein delivery also appeared to influence outcomes. TRIAL REGISTRATION: ClinicaTrials.gov NCT: 03634943.

Soil, but not cultivar, shapes the structure of arbuscular mycorrhizal fungal assemblages associated with strawberry.

Arbuscular mycorrhizal fungi are widespread plant symbionts occurring in most agricultural crops, where they can play key roles in the growth and health of their plant hosts. Plant benefits can depend on the identity of the associated arbuscular mycorrhizal fungi (AMF), but little is known about the identity of the fungal partners in most agricultural systems. In this study, we describe the AMF assemblages associated with four cultivars of strawberry in an outdoor experiment using two field soils with different origin and management history. Assemblages were characterised by clone library sequencing of 18S rRNA gene fragments. Soil dramatically influenced the degree of mycorrhizal colonisation and AMF assemblage structure in the roots. No differences were observed between cultivars. Fungi belonging to the genus Acaulospora dominated the AMF assemblages in one soil, but they were not detected in the other. These results suggest that physicochemical soil characteristics and management can play a role in determining the identity and structure of microbial communities associated with particular hosts in agricultural systems.

Association between acute myocardial infarction and death in 386 patients with a thrombus straddling a patent foramen ovale.

BACKGORUND: Right atrial thrombi are rarely found straddling a patent foramen ovale (PFO). A thrombus straddling a PFO (TSPFO), also known as impending paradoxical embolism, is a medical emergency associated with up to 11.5% risk of death within 24 h of being diagnosed. We hypothesized that acute myocardial infarction (MI) and ischemic stroke (IS) diagnosed upon the admission of patients with TSPFO are associated with increased risk of death. We also investigated if specific acute therapies are associated with reduced in-hospital mortality. METHODS: We performed a systematic search including case reports and series of adult patients with TSPFO published from 1950 to October 30, 2020. We gathered patient-level data and we applied a logistic regression model to evaluate on the risk of in-hospital death. We performed time-trends and several sensitivity analyses. RESULTS: We included 386 cases with a TSPFO comprised in 359 publications. The median age was 61 years and 51.2% were females. Fifty (13.0%) patients died during hospital stay, 82 (21.2%) had an acute IS, and 18 (4.6%) had an acute MI diagnosed upon admission. Acute MI (OR 7.83, 95%CI 2.70-22.7; P < 0.0001), but not IS, was associated with increased risk of death. Right atrial thrombectomy was associated with a 65% decreased in-hospital mortality (OR 0.35, 95%CI 0.18-0.70, P = 0.003). Results remained unchanged on sensitivity analyses. CONCLUSION: In this systematic review of 386 cases of TSPFO, acute MI but not IS was associated with 8-fold increased risk of death, while surgical thrombectomy was associated with a significant 65% reduction of in-hospital mortality.

Human Leukocyte Antigens -DQA1 and -DQB1 Alleles in Patients With Common Warts.

Introduction The human papillomavirus induces the formation of lesions in different epithelia. Several studies describe an association of class II human leukocyte antigen with genital lesions, implying that they could also be related to the presence of common warts. The goal of this work was to determine the frequency of human leukocyte antigens (HLA)-DQA1 and HLA-DQB1 in Mexicans with common warts. Methods Thirty-two patients with a diagnosis of common warts, without any other systemic disease, and 100 healthy subjects from the same geographic area were recruited. The second exon of the HLA-DQA1 and HLA-DQB1 loci was typed by dot-blot and chemiluminescence. Results Alleles DQA1*03:01:01 (P = 0.021) and DQB1*03:02 (P = 0.036) were associated with the presence of skin warts. DQA1*04:01-DQB1*04:02 (P = 0.009) and DQA1*03:01:01-DQB1*03:02 (P = 0.044) were the most frequent haplotypes in patients. Conclusion In conclusion, the results of our study showed that the alleles DQA1 *03:01:01, DQB1*03:02, DQA1 *04:01, and DQB1*04:02 were associated with susceptibility to common warts, while DQA1*05:01 was significantly diminished in them. Consequently, the haplotypes DQA1*04:01-DQB1*04: 02 and DQA1*03:01:01-DQB1*03:02 were found to be associated with susceptibility, and DQA1*05:01-DQB1*03:01 increased significantly in controls. Therefore, the alleles of the DQA1 and DQB1 genes that are associated with susceptibility could be presenting human papillomavirus (HPV) peptides to T lymphocytes that activate a Th2-type response (anti-inflammatory cytokines), which allows the development of skin warts in this population.

Perfect focusing of scalar wave fields in three dimensions.

A method to design isotropic inhomogeneous refractive index distribution is presented, in which the scalar wave field solutions propagate exactly on an eikonal function (i.e., remaining constant on the Geometrical Optics wavefronts). This method is applied to the design of "dipole lenses", which perfectly focus a scalar wave field emitted from a point source onto a point absorber, in both two and three dimensions. Also, the Maxwell fish-eye lens in two and three dimensions is analysed.

Speech perception performance as a function of stimulus pulse rate and processing strategy preference for the Cochlear Nucleus CI24RE device: relation to perceptual threshold and loudness comfort profiles.

Current cochlear implants can operate at high pulse rates. The effect of increasing pulse rate on speech performance is not yet clear. Habituation to low rates may affect the outcome. This paper presents the results of three subsequent studies using different experimental paradigms, applying the Nucleus CI24RE device, and conducted by ten European implant teams. Pulse rate per channel varied from 500 to 3500 pulses per second with ACE and from 1200 to 3500 pps with CIS strategy. The results showed that the first rate presented had little effect on the finally preferred rate. Lower rates were preferred. The effect of pulse rate on word scores of post-linguistic implantees was small; high rates tended to give lower scores. However, there were no significant differences between the word scores across subjects if collected at the individually preferred pulse rate. High pulse rates were preferred when the post-implantation threshold was low.