Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications.

BACKGROUND: This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN). METHODS: This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and 48-EEN vs EN started after 48 h (48-LEN). RESULTS: Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01). CONCLUSION: EEN may improve nutrient delivery, reduce time on MV, and prevent constipation in critically ill children. No relevant differences between 24-EEN and 48-EEN were found. Cardiac disease, MV, and age older than 12 months were risk factors associated with LEN.

Relationships among molecular, physicochemical and digestibility characteristics of Andean tuber starches.

This study aimed to determine and correlate the physicochemical, thermal, pasting, digestibility and molecular characteristics of native starches, such as mashua (Tropaeolum tuberosum R. and P.), oca (Oxalis tuberosa Mol.), and olluco (Ullucus tuberosus C.), which were extracted via successive washing and sedimentation. The morphology of native starches was determined by scanning electron microscopy, granule size distribution, thermal properties, pasting properties, X-ray diffraction (XRD), amylopectin chain-length distribution and amylose and amylopectin molecular weights. Mashua starch was smaller in size than oca and olluco starches. Moreover, the granules of mashua starch were round in shape, whereas those of oca and olluco starches were ellipsoidal in shape. The B XRD spectra showed similar profiles for the three Andean tuber starches. Mashua and olluco starches exhibited the lowest gelatinization temperatures and enthalpy values, and olluco amylopectin exhibited a longer chain length than mashua and oca starches. The resistant starch of gelatinized and ungelatinized samples exhibited a positive and strong correlation with the molecular properties of amylose and amylopectin, gelatinization enthalpy and molecular order.

Nutritional status and nutrition support in critically ill children in Spain: Results of a multicentric study.

OBJECTIVES: Critically ill children are often malnourished and require nutrition support (NS). Early enteral nutrition (EEN) seems to be safe in critically ill patients. However, there is a scarcity of data about the management of EEN in sick pediatric patients. The aim of this study was to analyze the nutritional status, NS characteristics, macronutrient supply, and associations between NS and outcomes in critically ill children in Spain. METHODS: This was a multicentric, prospective, cross-sectional study involving critically ill children who received NS and with an expected length of stay (LOS) in the pediatric intensive care unit of ≥3 d. Anthropometric variables, characteristics of NS, EEN, nutrient supply, and complications were recorded. RESULTS: We enrolled 86 children. Undernutrition and overweight were more prevalent in children ≤2 y of age than in older children (undernutrition: 40 versus 19%, respectively; overweight: 22.2 versus 14.3%, respectively). Being overweight was associated with a shorter PICU LOS (5.8 ± 2 versus 9.8 ± 6.5; P = 0.005). EN was the preferred method for nutrient delivery. EEN was administered to 58.1% of patients and was more common in children >2 y of age than in younger patients (73.1 versus 44.4%; P = 0.015). EEN was safe and was associated with a higher caloric intake (81.6 ± 35.3 versus 59.6 ± 36.6; P = 0.019). There was a negative correlation between mean time to EN initiation and maximum energy supply (r = -0.32; P = 0.07). CONCLUSIONS: Malnutrition was prevalent among critically ill children in Spain. Being overweight was associated with a shorter PICU LOS. EEN was safe and was associated with a higher caloric intake; however, it is rarely used in PICUs in Spain.

Metabolic Profiling Reveals Biochemical Pathways Responsible for Eelgrass Response to Elevated CO2 and Temperature.

As CO2 levels in Earth's atmosphere and oceans steadily rise, varying organismal responses may produce ecological losers and winners. Increased ocean CO2 can enhance seagrass productivity and thermal tolerance, providing some compensation for climate warming. However, the metabolic shifts driving the positive response to elevated CO2 by these important ecosystem engineers remain unknown. We analyzed whole-plant performance and metabolic profiles of two geographically distinct eelgrass (Zostera marina L.) populations in response to CO2 enrichment. In addition to enhancing overall plant size, growth and survival, CO2 enrichment increased the abundance of Calvin Cycle and nitrogen assimilation metabolites while suppressing the abundance of stress-related metabolites. Overall metabolome differences between populations suggest that some eelgrass phenotypes may be better suited than others to cope with an increasingly hot and sour sea. Our results suggest that seagrass populations will respond variably, but overall positively, to increasing CO2 concentrations, generating negative feedbacks to climate change.

Delivery in breech presentation: Perinatal outcome and neurodevelopmental evaluation at 18 months of life.

OBJECTIVES: To compare maternal and perinatal outcomes, including neurodevelopmental results at 18 months of life, between term breech and cephalic deliveries. STUDY DESIGN: In this longitudinal retrospective study of mothers seen at the Maternity and Paediatric University Hospital of the Canary Islands delivery unit from November 1, 2011, to October 31, 2012, we compared maternal and perinatal outcomes associated with breech or cephalic presentation of the foetus. A second analysis was performed to compare breech births, differentiating between whether a vaginal delivery attempt was made or if caesarean section (C-section) without labour had been directly scheduled. The psychomotor development of children 18 months after birth was assessed using the Haizea-Llevant scale. RESULTS: A total of 130 breech deliveries were matched with 130 cephalic deliveries. No perinatal mortality occurred in either group. The C-section percentage was greater in the breech presentation group compared with the cephalic delivery group (72.3 % vs. 14.6 %; p < 0.001). Children in the breech presentation had a threefold increased risk for Apgar scores <7 at 1 min (OR 3.2; 95 % CI: 1.2-8.4; p = 0.016) compared with cephalic presentation. These differences disappeared 5 min after birth. No differences were observed in moderate to severe neonatal morbidity between the breech and cephalic presentation groups. There were no differences between groups in neurodevelopmental outcomes. Of 130 pregnancies with breech presentation, 79 (60.8 %) made a vaginal delivery attempt, and 51 (39.2 %) were planned C-sections. Women who attempted vaginal breech delivery were younger and had a history of previous pregnancy. Apgar scores <7 at 1 min were more frequent in the vaginal delivery attempt group (27.9 % vs. 5.9 %; p = 0.002). A high percentage of type III resuscitation (36.5 % vs. 14.3 %; p = 0.007) and Neonatology admission (22.8 % vs. 5.9 %; p = 0.013) was observed in the vaginal delivery attempt group. Except for Apgar scores <7 at 1 min, none of these associations was significant after adjusting for nulliparity and maternal age. The mode of delivery was not associated with moderate to severe perinatal outcomes. CONCLUSION: The implementation of a specific protocol for selecting pregnant women with breech presentation as candidates for vaginal delivery achieved perinatal outcomes similar to births in cephalic presentation.

Physicochemical, functional and morphological characterization of starches isolated from three native potatoes of the Andean region.

Three varieties of native potato (Imilla blanca, Imilla negra and Loc'ka) that grow in the Andean region at more than 3800 m.a.s.l. were selected fot the extraction and characterization or their starch. Instrumental techniques such as scanning electron microsocopic (SEM), differential scanning calorimetry (DSC), Fourier transformed infrarred spectroscopy (FTIR), X-ray diffraction, colorimetry and polarized light microscopy were used. The results showed that only Loc'kás starch had a unimodal granule size distribution, whereas Imilla negra and Imilla blanca starches showed two and three granule size populations, respectively. The starch from Imilla negra showed higher apparent amylose content, peak viscosity, phosphorous content and paste clarity. The starch from Imilla blanca showed high relative crystallinity, while Imilla blanca and Imilla negra had higher intensity ratios than that from Loc'ka, suggesting high molecular order. Cooked starch from Imilla negra showed higher resistant starch (RS) fraction than the other starches studied.

Rotura espontánea de varices uterinas como causa de hemoperitoneo en la segunda mitad de la gestación / Spontaneous uterine rupture as a cause of hemoperitoneum in the second half of pregnancy

Introducción: el hemoperitoneo durante el embarazo, secundario a la rotura espontánea de varices uterinas, es una condición clínica infrecuente aunque potencialmente letal. La mortalidad materna puede llegar al 49%, aunque, con la rápida atención, ha descendido hasta un 3,4%; la mortalidad perinatal alcanza el 31%. La clínica es inespecífi ca, dolor abdominal y choque hipovolémico, asociado o no a sufrimiento fetal. La laparotomía exploradora es necesaria en estos casos, junto con la reposición de líquidos y sangre. Caso clínico: se presenta el caso de una septigesta de 44 años con edad gestacional de 28 semanas y cinco días, que presentaba dolor abdominal intenso e inestabilidad hemodinámica en la que se objetivó bradicardia fetal mantenida. Se indicó cesárea urgente ante sospecha de desprendimiento prematuro de placenta normoinserta, comprobándose importante hemoperitoneo procedente de dos grandes varices de la pared anterior del útero. Se realizó una histerectomía puerperal al no controlarse el sangrado con puntos de hemostasia (AU)

Background: The hemoperitoneum during pregnancy, secondary to spontaneous rupture of uterine varices, is an infrequent clinic condition but potentially lethal clinical condition. Maternal mortality can reach 49%, although with fast service, has fallen to 3.4%; perinatal mortality is 31%. Symptoms are nonspecifi c, abdominal pain and hypovolemic shock, which may be or not fetal distress. Exploratory laparotomy is necessary in these cases, with fl uid replacement and blood. Case report: We present the case of a 44 septigesta with a gestational age of 28 weeks and fi ve days, which had severe abdominal pain and hemodynamic instability that sustained fetal bradycardia was observed. Emergency cesarean section for suspected abruptio normoinserta placenta was realized and we found important hemoperitoneum from two large veins of the anterior wall of the uterus. Puerperal hysterectomy was performed because was not possible to control the bleeding with hemostasis stitches (AU)

La reducción de daños y riesgos en el contexto penitenciario español / Harm and risk reduction in Spanish prisons

Desde la experiencia de Fundación Atenea en el abordaje de los consumos de drogas en prisión se plantean dificultades y retos en la incorporación del paradigma de la reducción de daños y riesgos en una institución cerrada como son los centros penitenciarios. La población reclusa supera a la población general en el consumo de drogas ilegales y se han establecido correlaciones entre el consumo de drogas y el delito. Acompañar a las personas desde la reducción de riesgos pasa necesariamente por contextualizar la intervención e incorporar en nuestra acción a todos los condicionantes que rodean al consumo de drogas en prisión. Se desarrollan algunos elementos metodológicos que mejoran la vida de las personas en prisión y fuera de ella más allá del consumo en sí mismo. Sin perder de vista el objetivo de mejorar las condiciones socio sanitarias de las personas presas y ofrecer alternativas para una mejor reincorporación social tras el cumplimiento de la condena

Fundación Atenea’s experience in the approach to drug use in prisons entail some difficulties and challenges when attempting to incorporate the paradigm of risk assessment and harm reduction in a closed institution such as penitentiary centers. Consumption of illegal druges in prison populations exceed that of the general population. It has been proved that there is a significant correlation between crime and drug use. Accompanying people from a harm reduction approach necessarily involves contextualizing intervention and considering all the conditions that surround drug use and abuse in prison in our intervention. Some methodological elements have been developed in order to improve the living conditions of people in prison and outside, beyond consumption itself. This is all undertaken without losing sight of the objective of improving the social and health conditions of the inmates and offering alternatives for better social reintegra-tion after serving their sentence

Atención al paciente diabético en un área de salud: ciclo de mejora / Taking care of patients with diabetes in ah health care area: a series of improvements

Objetivo: Mejorar la calidad de la asistencia que recibe el paciente diabético en un área de salud. Pacientes y método: Se estudió a pacientes con diabetes mellitus (DM) > 14 años de edad. El período de observación se prolongó desde la apertura de la historia clínica hasta el 30 de septiembre de 1999 para los criterios 1, 2, 3 y 7 de la cartera de servicios, y desde el 1 de octubre de 1998 al 30 de septiembre de 1999 para el resto de criterios. El estudio tuvo una dimensión de calidad científico-técnica. Los datos fueron de tipo procesual y los criterios fueron explícitos y normativos. Se aplicaron las normas técnicas mínimas de la cartera de servicios en atención primaria. Los datos del muestreo se obtuvieron de las historias clínicas de los pacientes incluidos en el programa de diabetes mellitus (n.o de pacientes incluidos en la muestra = 691; IC del 95 por ciento; precisión (e) = 10 por ciento). El muestreo fue sistemático y estratificado por cupos. Se realizó una revisión interna por pares y, con posterioridad, se llevó a cabo un análisis de resultados y una propuesta de medidas correctoras: a) transmisión de los resultados a los equipos de atención primaria; b) implantar una hoja de seguimiento del programa de diabetes mellitus, y c) realización de sesiones en el equipo de atención primaria para unificar las actividades, sesiones de formación continuada, segunda fase del estudio y comparación de resultados. Resultados: En la primera fase se incluyó el 95,8 ñ 1,5 por ciento de los pacientes. Los datos de la anamnesis revelaron hipertensión arterial en el 80,3 ñ 3 por ciento, dislipemias en el 59,9 ñ 3,7 por ciento; auscultación cardiopulmonar en el 63 ñ 3,6 por ciento, evaluación de los reflejos osteotendinosos en el 45,9 ñ 3,7 por ciento, valoración de la sensibilidad en el 52 ñ 3,7 por ciento, electrocardiograma en el 73,1 ñ 3,3 por ciento y síntomas de hipoglucemia en el 71,9 ñ 3,4 por ciento. En la segunda fase (al año de implantar las medidas correctoras) hubo un 97 ñ 1,3 por ciento de pacientes bien incluidos (p = 0,1). En la anamnesis se apreció hipertensión arterial en el 86,4 ñ 2,5 por ciento (p = 0,001) y dislipemia en el 73 ñ 3,3 por ciento (p = 0,001). El 66,2 ñ 3,5 por ciento presentaba auscultación cardiopulmonar (p = 0,09); en el 54,4 ñ 3,7 por ciento se había evaluado los reflejos osteotendinosos (p = 0,0006), en el 58,8 ñ 3,6 por ciento, la sensibilidad (p = 0,005), en el 76,9 ñ 3,1 por ciento se realizó un electrocardiograma (p = 0,005) y el 76,1 ñ 3,1 por ciento presentaba síntomas de hipoglucemia (p = 0,04). Conclusiones: Las medidas correctoras implantadas son válidas para mejorar la calidad de la atención a los pacientes con diabetes mellitus del área, ya que se ha observado una mejoría en los criterios que evalúan una correcta anamnesis y exploración (AU)