Network meta-analysis of the effect of preoperative carbohydrate loading on recovery after elective surgery.

BACKGROUND: Three meta-analyses have summarized the effects of preoperative carbohydrate administration on postoperative outcomes in adult patients undergoing elective surgery. However, these studies could not account for the different doses of carbohydrate administered and the different controls used. Multiple-treatments meta-analysis allows robust synthesis of all available evidence in these situations. METHODS: Article databases were searched systematically for RCTs comparing preoperative carbohydrate administration with water, a placebo drink, or fasting. A four-treatment multiple-treatments meta-analysis was performed comparing two carbohydrate dose groups (low, 10-44 g; high, 45 g or more) with two control groups (fasting; water or placebo). Primary outcomes were length of hospital stay and postoperative complication rate. Secondary outcomes included postoperative insulin resistance, vomiting and fatigue. RESULTS: Some 43 trials involving 3110 participants were included. Compared with fasting, preoperative low-dose and high-dose carbohydrate administration decreased postoperative length of stay by 0·4 (95 per cent c.i. 0·03 to 0·7) and 0·2 (0·04 to 0·4) days respectively. There was no significant decrease in length of stay compared with water or placebo. There was no statistically significant difference in the postoperative complication rate, or in most of the secondary outcomes, between carbohydrate and control groups. CONCLUSION: Carbohydrate loading before elective surgery conferred a small reduction in length of postoperative hospital stay compared with fasting, and no benefit in comparison with water or placebo.

Cohort profile: Pacific Islands Families (PIF) growth study, Auckland, New Zealand.

PURPOSE: This article profiles a birth cohort of Pacific children participating in an observational prospective study and describes the study protocol used at ages 14-15 years to investigate how food and activity patterns, metabolic risk and family and built environment are related to rates of physical growth of Pacific children. PARTICIPANTS: From 2000 to 2015, the Pacific Islands Families Study has followed, from birth, the growth and development of over 1000 Pacific children born in Auckland, New Zealand. In 2014, 931 (66%) of the original cohort had field measures of body composition, blood pressure and glycated haemoglobin. A nested subsample (n=204) was drawn by randomly selecting 10 males and 10 females from each decile of body weight. These participants had measurement of body composition by dual-energy X-ray absorptiometry, food frequency, 6 min walk test and accelerometer-determined physical activity and sedentary behaviours, and blood biomarkers for metabolic disease such as diabetes. Built environment variables were generated from individual addresses. FINDINGS TO DATE: Compared to the Centres for Disease Control and Prevention (CDC) reference population with mean SD scores (SDS) of 0, this cohort of 931 14-year-olds was taller, weighed more and had a higher body mass index (BMI) (mean SDS height >0.6, weight >1.6 and BMI >1.4). 7 of 10 youth were overweight or obese. The nested-sampling frame achieved an even distribution by body weight. FUTURE PLANS: Cross-sectional relationships between body size, fatness and growth rate, food patterns, activity patterns, pubertal development, risks for diabetes and hypertension and the family and wider environment will be examined. In addition, analyses will investigate relationships with data collected earlier in the life course and measures of the cohort in the future. Understanding past and present influences on child growth and health will inform timely interventions to optimise future health and reduce inequalities for Pacific people.

Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis.

BACKGROUND: The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities. METHODS: A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i. RESULTS: A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention. CONCLUSION: Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.

Protein for the critically ill patient--what and when?

Critical illness is characterised by catabolism of the skeletal muscle that releases amino acids for protein synthesis to support tissue repair, immune defence and inflammatory and acute-phase responses. Protein requirements for these patients have generally been based on levels that result in the lowest catabolic rates or most favourable nitrogen balance. The definition of these levels, in particular, in relation to indexing to a measure of patient weight or lean body mass, is controversial. Furthermore, optimal nitrogen balance may not necessarily equate to best clinical outcome. There is some evidence that administration of specific amino acids may be advantageous at least during the early or most catabolic phases of illness, in order to support the specific amino acid requirements of the metabolic pathways activated by the injury or infection. Current widely used guidelines differ in the protein prescription they recommend and in the timing of administration in relation to intensive care admission. A pressing need exists for well-designed randomised trials that compare differing levels of protein or amino acid provision, and the timing of this provision, for their effects on clinical endpoints.

Bioimpedance prediction of fat-free mass from dual-energy X-ray absorptiometry in a multi-ethnic group of 2-year-old children.

BACKGROUND/OBJECTIVES: Bioimpedance analysis (BIA) is a simple, convenient and widely used tool for the measurement of body composition in population surveys and surveillance. Prediction equations based on BIA applicable to preschool children are available but are based on total body water estimation and have not been developed across multiple ethnic groups. Our aim was to develop a BIA-based equation in a multi-ethnic sample of 2-year old using fat-free mass (FFM) from dual-energy X-ray absorptiometry (DXA) as criterion measure. SUBJECTS/METHODS: Single-frequency hand-to-foot BIA (model BIM4, Impedimed) and whole-body DXA measurements were carried out in 77 (35 boys, 42 girls; 27 European, 20 Polynesian, 30 Asian and other) healthy preschool children (age range 22-38 months). Body mass index s.d. scores were 0.41 ± 1.23 for boys and 0.61 ± 1.09 for girls. The performance of published equations applicable to this age group was assessed. The predicted residual sum of squares method was used to develop and cross-validate a multiple regression equation relating FFM to BIA measures. RESULTS: Published equations performed poorly for estimating FFM in this group of children. The prediction equation developed in all 77 children was: FFM (kg)=0.367 height(cm)(2)/resistance+0.188 weight (kg)+0.077 height (cm)+0.273 sex (male=1, female=0)-2.490, R(2)=0.89, standard error of estimate=0.50 kg. Ethnicity and age did not add significantly to the model. CONCLUSIONS: We have developed an equation that may have application for prediction of FFM in 2-3-year-old children, which does not require determination of hydration factors. Further work should be carried out using DXA scanning to extend the applicable age range.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery.

BACKGROUND: Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double-blind randomized trial. METHODS: Patients undergoing elective colorectal surgery or liver resection were randomized to oral CHO or placebo drinks to be taken on the evening before surgery and 2 h before induction of anaesthesia. Primary outcomes were postoperative length of hospital stay and fatigue measured by visual analogue scale. RESULTS: Sixty-nine and 73 patients were evaluated in the CHO and placebo groups respectively. The groups were well matched with respect to surgical procedure, epidural analgesia, laparoscopic procedures, fasting period before induction and duration of surgery. Postoperative changes in fatigue score from baseline did not differ between the groups. Median (range) hospital stay was 7 (2-35) days in the CHO group and 8 (2-92) days in the placebo group (P = 0.344). For patients not receiving epidural blockade or laparoscopic surgery (20 CHO, 19 placebo), values were 7 (3-11) and 9 (2-48) days respectively (P = 0.054). CONCLUSION: Preoperative CHO treatment did not improve postoperative fatigue or length of hospital stay after major abdominal surgery. A benefit is not ruled out when epidural blockade or laparoscopic procedures are not used. REGISTRATION NUMBER: ACTRN012605000456651 (http://www.anzctr.org.au).

Systematic review on the efficacy and safety of injectable bulking agents for passive faecal incontinence.

OBJECTIVE: The aim of this study was to systematically review all published evidence to determine the efficacy and safety of injectable bulking agents for passive faecal incontinence (FI) in adults. METHOD: Electronic searches were performed for MEDLINE, EMBASE, ISI Web of Knowledge and other relevant databases. Hand searching of relevant conference proceedings was undertaken. Studies were considered if they met the predefined inclusion criteria of more than ten adult patients and receiving an injectable bulking agent for passive FI with a validated means of assessing preoperative and postoperative incontinence. RESULTS: Thirteen case series studies and one randomized placebo-controlled trial (RCT) were included with a total of 420 patients. Two completed RCTs with placebo control were identified but results were unobtainable. Coaptite, Contigen, Durasphere, EVOH and PTQ injections were assessed with 24, 73, 83, 21 and 208 patients respectively. Most studies reported a statistically significant improvement in incontinence scores and quality of life. No statistically significant difference was found between the treatment and placebo arms in the RCT. No serious adverse events were reported. CONCLUSIONS: Currently there is little evidence for the effectiveness of injectable bulking agents in managing passive FI. The inability to obtain results from two further RCTs concerned the reviewers and hindered their ability to make strong recommendations. The identified injectable bulking agents appear to be safe with only minor complications reported.

Systematic review on ventral rectopexy for rectal prolapse and intussusception.

OBJECTIVE: This systematic review assesses the effectiveness of ventral rectopexy (VR) surgery for treatment of rectal prolapse (RP) and rectal intussusception (RI) in adults. Method MEDLINE, EMBASE, Scopus and other relevant databases were searched to identify studies. Randomized controlled trials or nonrandomized studies with more than 10 patients receiving ventral mesh rectopexy surgery were considered for the review. RESULTS: Twelve nonrandomized case series studies with 728 patients in total are included in the review. Seven studies used the Orr-Loygue procedure (VR with posterior rectal mobilization to the pelvic floor) and five studies used VR without posterior rectal mobilization. Overall weighted mean percentage decrease in faecal incontinence (FI) rate was 45%. The weighted mean percentage decrease in constipation rate was 24%. Weighted mean recurrence rate was 3.4%. CONCLUSIONS: There are limitations in published literature on VR. The available data indicate that VR has low recurrence and improves FI in patients suffering from these conditions. There is a greater reduction in postoperative constipation if VR is used without posterior rectal mobilization.

Indices of fatness and relationships with age, ethnicity and lipids in New Zealand European, Maori and Pacific children.

BACKGROUND/OBJECTIVES: To investigate the relationships between body mass index (BMI), body fatness, ethnicity, age and blood lipids. SUBJECTS/METHOD: In a subsample (N=643) of the 2002 New Zealand Child Nutrition Survey (N=3275, age 5-14 years) consisting Maori (89 boys, 69 girls), Pacific (154 boys, 194 girls) and European (71 boys, 66 girls) ethnic groups, fat-free mass (FFM) was determined by bioimpedance analysis. FFM index (FFMI, FFM/height(2)), fat mass index (FMI, fat mass/height(2)) and percentage body fat (%BF) were derived. Plasma total cholesterol and high-density lipoprotein (HDL) cholesterol were measured in 515 (80%) of these children. RESULTS: For the same BMI, %BF was lower in Pacific Island (P<0.0001) and Maori (P<0.0001) girls compared with European but for boys there were no ethnic differences. Cross-sectional analysis across ages using Hattori charts clearly showed sexual dimorphism with girls having a higher FMI, FFMI and BMI than boys by the age of 13 year. Both Pacific girls and boys showed upward trends in FFMI and FMI with age that were significantly higher than those of the other ethnicities. Adjusting for age, sex and ethnicity, %BF was a better predictor (R(2)=0.090, P=0.0002) of total cholesterol than BMI (R(2)=0.061, P=0.049) or waist (R(2)=0.075, P=0.013) while FFMI was the best predictor of HDL cholesterol (R(2)=0.15, P<0.0001) and waist was the best predictor of the total cholesterol/HDL cholesterol ratio (R(2)=0.17, P<0.0001). CONCLUSIONS: Measurements of body fat and indices of body fatness additional to BMI in multiethnic paediatric populations allow changes in fat mass and FFM to be tracked and improve the ability to predict dyslipidaemia.

Bioelectric impedance spectroscopy underestimates fat-free mass compared to dual energy X-ray absorptiometry in incurable cancer patients.

BACKGROUND/OBJECTIVES: Weight loss is frequently seen in advanced cancer. Bioelectrical impedance spectroscopy (BIS) is a convenient method for estimating body composition. We examined in a prospective, comparative study if BIS could accurately estimate fat-free mass (FFM) in cancer patients compared to dual-energy X-ray absorptiometry (DXA). SUBJECTS/METHODS: The study was based on 132 consecutive incurable cancer patients with solid tumours in a University hospital outpatient clinic. Comparison of FFM from DXA and BIS with standard and revised equations. Bland-Altman plots, t-tests and linear regression analysis were used to evaluate agreement and differences between methods. RESULTS: BIS significantly underestimated mean FFM with 7.6+/-4.7 kg compared to DXA (P<0.001). Bias was significantly correlated to % weight loss (r=0.32), systemic inflammation as measured by C-reactive protein (r=0.29), malnutrition as assessed by low insulin-like growth factor-1 (r=-0.23) and inversely to the per cent body fat estimated by DXA (P=-0.61) and body mass index (BMI; r=-0.30). Revised BIS equations taking BMI into account reduced bias significantly but still with great individual variation. CONCLUSIONS: BIS by standard equations grossly underestimates FFM compared to DXA in cancer patients. This bias is related to weight loss, malnutrition and systemic inflammation. Revised equations improved FFM estimates, but with large individual variation. Thus, BIS with standard equations is not suitable to estimate FFM in patients with cachexia, inflammation and malnutrition.

BMI, fat and muscle differences in urban women of five ethnicities from two countries.

OBJECTIVE: To investigate body composition differences, especially the relationship between body mass index (BMI) and percent body fat (%BF), among five ethnic groups. DESIGN: Cross-sectional. SUBJECTS: Seven hundred and twenty-one apparently healthy women aged 18-60 years (BMI: 17.4-54.0 kg/m(2)) from South Africa (SA, 201 black, 94 European) and New Zealand (NZ, 173 European, 76 Maori, 84 Pacific, 93 Asian Indian). MEASUREMENTS: Anthropometry, including waist circumference, and total, central and peripheral body fat, bone mineral content and total appendicular skeletal muscle mass (ASMM) derived from dual X-ray absorptiometry. RESULTS: Regression analysis determined that at a BMI of 30 kg/m(2), SA European women had a %BF of 39%, which corresponded to a BMI of 29 for SA black women. For a BMI of 30 kg/m(2) in NZ Europeans, equivalent to 43% body fat, the corresponding BMIs for NZ Maori, Pacific and Asian Indian women were 34, 36 and 26 kg/m(2), respectively. Central fat mass was lower in black SA than in European SA women (P<0.001). In NZ, Pacific women had the lowest central fat mass and highest ASMM, whereas Asian Indian women had the highest central fat mass, but lowest ASMM and bone mineral content. CONCLUSIONS: The relationship between %BF and BMI varies with ethnicity and may be due, in part, to differences in central fatness and muscularity. Use of universal BMI or waist cut-points may not be appropriate for comparison of obesity prevalence among differing ethnic groups, as they do not provide a consistent reflection of adiposity and fat distribution across ethnic groups.

A novel model used to compare water-perfused and solid-state anorectal manometry.

BACKGROUND: Anal pressures are commonly measured using water-perfused and solid-state manometers. We constructed a dynamic model of the anus to compare the agreement and reproducibility of the two types of manometers. METHODS: The model system was constructed using a pig anorectum together with an inflatable bowel sphincter. The pig anorectum was mounted on a jig and the sphincter was inserted external to the internal sphincter. The sphincter pressure was adjusted over the range 20 to 185 mmHg. At each of 24 constant sphincter pressures, triplicate readings were carried out with both manometers. The first measurement by each method was used for the comparison. The replicate measurements were used to calculate measures of repeatability for each method. RESULTS: Measurements by the two manometers were highly correlated (r=0.97). Measurements by the solid state manometer were higher than the water-perfused manometer by 8.1+/-12.2 mmHg (mean+/-SD). Precision (coefficient of variation) for the solid-state manometer (2.8%) was better than for the water-perfused manometer (8.3%). CONCLUSIONS: The new model of the anal canal shows promise as a tool for assessing physiological interventions. The solid-state manometer has many advantages over the water-perfused manometer, providing more consistent measurements at clinically relevant pressures.

Prediction of fat-free mass by bioimpedance analysis in migrant Asian Indian men and women: a cross validation study.

BACKGROUND: Bioimpedance analysis (BIA) is a fast and convenient field technique for estimation of total body fat-free mass (FFM). However, bioimpedance-based prediction equations have been developed in predominantly white populations and little information is available on their usefulness in Asian Indian populations. OBJECTIVE: To develop a prediction equation for FFM based on BIA measurements applicable to a migrant population of Asian Indians and to investigate the predictive accuracy of published BIA-based equations in this ethnic group. DESIGN: FFM was measured by dual-energy X-ray absorptiometry in 211 healthy adults (110 men, 101 women; age ranges 19-74 year) of Asian Indian ethnicity and used as the reference measure to develop prediction equations based on single-frequency BIA measurements of resistance and reactance. A cross-validation technique was applied. Predictive accuracy of published BIA-based equations was assessed in this sample. RESULTS: Sex-specific equations developed in the entire group included height2/resistance and body weight as predictors (R2=0.84 and 0.70 and standard errors of estimate of 2.8 and 2.0 kg for males and females, respectively; CV: 6%). Of published equations examined, one predicted FFM satisfactorily in men with nonsignificant bias and may be applicable to Asian Indian populations. None of the published equations tested performed satisfactorily in women. CONCLUSIONS: Bioimpedance-based equations for predicting FFM developed specifically in Asian Indians are recommended for field studies designed to measure body composition of this ethnic group.

Estimation of body fatness from body mass index and bioelectrical impedance: comparison of New Zealand European, Maori and Pacific Island children.

OBJECTIVE: To compare percentage body fat (%BF) for a given body mass index (BMI) among New Zealand European, Maori and Pacific Island children. To develop prediction equations based on bioimpedance measurements for the estimation of fat-free mass (FFM) appropriate to children in these three ethnic groups. DESIGN: Cross-sectional study. Purposive sampling of schoolchildren aimed at recruiting three children of each sex and ethnicity for each year of age. Double cross-validation of FFM prediction equations developed by multiple regression. SETTING: Local schools in Auckland. SUBJECTS: Healthy European, Maori and Pacific Island children (n=172, 83 M, 89 F, mean age 9.4+/-2.8(s.d.), range 5-14 y). MEASUREMENTS: Height, weight, age, sex and ethnicity were recorded. FFM was derived from measurements of total body water by deuterium dilution and resistance and reactance were measured by bioimpedance analysis. RESULTS: For fixed BMI, the Maori and Pacific Island girls averaged 3.7% lower %BF than European girls. For boys a similar relation was not found since BMI did not significantly influence %BF of European boys (P=0.18). Based on bioimpedance measurements a single prediction equation was developed for all children: FFM (kg)=0.622 height (cm)(2)/resistance+0.234 weight (kg)+1.166, R(2)=0.96, s.e.e.=2.44 kg. Ethnicity, age and sex were not significant predictors. CONCLUSIONS: A robust equation for estimation of FFM in New Zealand European, Maori and Pacific Island children in the 5-14 y age range that is more suitable than BMI for the determination of body fatness in field studies has been developed.

Sequential changes in the metabolic response to orthotopic liver transplantation during the first year after surgery.

OBJECTIVE: To quantify the sequential changes in the metabolic response occurring in patients with end-stage liver disease after orthotopic liver transplantation (OLT). SUMMARY BACKGROUND DATA: Detailed quantification of the changes in energy expenditure, body composition, and physiologic function that occur in patients after OLT has not been performed. Understanding these changes is essential for the optimal management of these patients. METHODS: Fourteen patients who underwent OLT for end-stage liver disease had measurements of resting energy expenditure, body composition, and physiologic function immediately before surgery and 5, 10, 15, 30, 90, 180, and 360 days later. RESULTS: Resting energy expenditure was significantly elevated after surgery (24% above predicted), peaking around day 10 after OLT, when it averaged 42% above predicted. A significant degree of hypermetabolism was still present at 6 months, but at 12 months measured resting energy expenditure was close to predicted values. Before surgery, measured total body protein was 82% of estimated preillness total body protein. During the first 10 days after OLT, a further 1.0 kg (10%) of total body protein was lost, mostly from skeletal muscle. Only 54% of this loss was restored by 12 months. Significant overhydration of the fat-free body was seen before OLT, and it was still present 12 months later. Although significant losses of body fat and bone mineral occurred during the early postoperative period, only body fat stores were restored at 12 months. Both subjective fatigue score and voluntary hand grip strength improved rapidly after OLT to exceed preoperative levels at 3 months. At 12 months grip strength was close to values predicted for these patients when well. Respiratory muscle strength improved less markedly and was significantly lower than predicted normal levels at 12 months. CONCLUSIONS: Before surgery, these patients were significantly protein-depleted, overhydrated, and hypermetabolic. After surgery, the period of hypermetabolism was prolonged, restoration of body protein stores was gradual and incomplete, and respiratory muscle strength failed to reach expected normal values. Our measurements indicate that OLT does not normalize body composition and function and imply that a continuing metabolic stress persists for at least 12 months after surgery.

The effects of intensive glycaemic control on body composition in patients with type 2 diabetes.

AIM: To examine the effects of improved glycaemic control over 20 weeks on the type and distribution of weight change in patients with type 2 diabetes who at baseline have poor glycaemic control. METHODS: Forty-three patients with type 2 diabetes and HbA1c > 8.9% were randomised to either intensive glycaemic control (IC) n = 21 or usual glycaemic control (UC) n = 22 for 20 weeks. Dual energy X-ray absorptiometry was used to assess the type and distribution of weight change during the study. RESULTS: After 20 weeks HbA1c was significantly lower in patients randomised to IC than UC (HbA1c IC 8.02 +/- 0.25% vs. UC 10.23 +/- 0.23%, p < 0.0001). In the IC group weight increased by 3.2 +/- 0.8 kg after 20 weeks (fat-free mass increased by 1.8 +/- 0.3 kg) compared to 0.02 +/- 0.70 kg in UC (p = 0.003). The gain in total body fat mass comprised trunk fat mass (IC 0.94 +/- 0.5 kg vs. UC 0.04 +/- 0.4 kg, p = 0.18) and peripheral fat mass (total body fat - trunk fat) (IC 0.71 +/- 0.32 kg vs. UC -0.21 +/- 0.28 kg, p = 0.04). Blood pressure and serum lipid concentrations did not change over time in either group. CONCLUSIONS: Intensive glycaemic control was associated with weight gain which was distributed in similar proportions between the central and peripheral regions and consisted of similar proportions of fat and fat-free mass. Blood pressure and serum lipid concentrations were not adversely affected.

Similarity of changes in body composition in intensive care patients following severe sepsis or major blunt injury.

Critically ill patients admitted to the intensive care unit with severe sepsis or major blunt injury undergo massive changes in body composition. We compared these changes in 12 patients with generalized peritonitis, and in 18 patients with major blunt injury over a 21-day period soon after their admission. Body composition was measured as soon as the patients were hemodynamically stable, and again 5, 10, and 21 days later. In both groups, losses in total body protein (TBP) were greatest over the first 10 days. TBP lost over the study period averaged 13.1 +/- 1.3 (SEM)% for the sepsis group, and 14.6 +/- 1.3% for the trauma group. Total body water (TBW) lost postresuscitation averaged 11.1 +/- 1.3 L and 6.7 +/- 1.1 L for the two groups, respectively, these changes largely being accounted for by changes in extracellular water (ECW). Our results demonstrate a striking similarity in the changes in total body protein for these two groups of critically ill patients. The sepsis patients retained approximately twice the volume of fluid of those with major trauma.

Sequential metabolic changes following induction of systemic inflammatory response in patients with severe sepsis or major blunt trauma.

We have recently completed studies in critically ill patients with severe sepsis or major trauma that investigated sequential changes in the metabolic response following admission to the intensive care unit. Protein, water, and energy metabolism were measured using in vivo neutron activation analysis, tracer dilution, dual-energy x-ray absorptiometry, and indirect calorimetry. Over the 3-week study period both groups of patients lost 13% of their total body protein. The severe sepsis patients retained twice the volume of fluid of those with major trauma, and the return to normal hydration in the sepsis group was correspondingly prolonged, especially for those in the elderly age group. In both groups of patients resting energy expenditure increased progressively over the first week to around 40% above normal and was still elevated 3 weeks from onset of illness. A twofold increase in total energy expenditure occurred in both groups of patients between the first and second weeks of critical care admission. The prolonged hypermetabolism throughout the study period was not reflected in the concentrations of circulating proinflammatory cytokines, which fell rapidly over the first week. The pattern of changes seen in plasma proinflammatory and antiinflammatory cytokine concentrations is similar for sepsis and trauma. The remarkably similar metabolic sequelae seen in critically ill patients following the onset of severe sepsis or major trauma may constitute a universal response to the induction of the systemic inflammatory response syndrome.