Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

BACKGROUND: Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS: This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS: We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION: Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING: Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

Consistency between cross-sectional and longitudinal SNP: blood lipid associations.

Various studies have linked different genetic single nucleotide polymorphisms (SNPs) to different blood lipids (BL), but whether these "connections" were identified using cross-sectional or longitudinal (i.e., changes over time) designs has received little attention. Cross-sectional and longitudinal assessments of BL [total, high-, low-density lipoprotein cholesterol (TC, HDL, LDL), triglycerides (TG)] and non-genetic factors (body mass index, smoking, alcohol intake) were measured for 2,002 Geneva, Switzerland, adults during 1999-2008 (two measurements, median 6 years apart), and 20 SNPs in 13 BL metabolism-related genes. Fixed and mixed effects repeated measures linear regression models, respectively, were employed to identify cross-sectional and longitudinal SNP:BL associations among the 1,516 (76%) study participants who reported not being treated for hypercholesterolemia at either measurement time. One-third more (12 vs. 9) longitudinal than cross-sectional associations were found [Bonferroni-adjusted two-tailed p < 0.00125 (=0.05/2)/20) for each of the four ensembles of 20 SNP:individual BL associations tested under the two study designs]. There was moderate consistency between the cross-sectional and longitudinal findings, with eight SNP:BL associations consistently identified across both study designs: [APOE.2 and APOE.4 (rs7412 and rs429358)]:TC; HL/LIPC (rs2070895):HDL; [APOB (rs1367117), APOE.2 and APOE.4 (rs7412 and rs429358)]:LDL; [APOA5 (rs2072560) and APOC III (rs5128)]:TG. The results suggest that cross-sectional studies, which include most genome-wide association studies (GWAS), can assess the large majority of SNP:BL associations. In the present analysis, which was much less powered than a GWAS, the cross-sectional study was around 2/3 (67%) as efficient as the longitudinal study.

Low prevalence of atrial fibrillation in asymptomatic adults in Geneva, Switzerland.

AIMS: To determine the prevalence of atrial fibrillation (AF) in a population-based sample of adults. METHODS AND RESULTS: Between January 2005 and December 2007 individuals aged > or =50 years, residents of the city of Geneva, who had participated in a previous random survey were invited for follow-up examination. AF was assessed on a single resting 6-lead ECG. Reported prevalences were standardized for the age distribution of Canton Geneva. Overall participation was 72.8%. Twenty-nine cases of AF (22 men) were diagnosed among 3285 subjects (1696 men). The crude prevalence of AF (95% CI) was 0.88% (0.86, 0.90) overall, but higher in men [1.30% (1.26, 1.34)] than in women [0.44% (0.41, 0.47)]. The age-standardized AF prevalence was slightly higher [overall: 0.94% (0.91, 0.97), men: 1.23% (1.19, 1.27), women: 0.54% (0.47, 0.61)]. AF prevalence increased with age in both sexes. A 'history of suspected arterial embolism' (brain or legs) was higher in the AF cases (10.3 vs. 3.3%; P = 0.03). CONCLUSION: This population-based survey of a general Swiss population indicates that the prevalence of AF remains below 1%. These results are less alarming than those from previous studies based on patients seeking medical care.

Undocumented migrants lack access to pregnancy care and prevention.

BACKGROUND: Illegal migration is an increasing problem worldwide and the so-called undocumented migrants encounter major problems in access to prevention and health care. The objective of the study was to compare the use of preventive measures and pregnancy care of undocumented pregnant migrants with those of women from the general population of Geneva, Switzerland. METHODS: Prospective cohort study including pregnant undocumented migrants presenting to the University hospital from February 2005 to October 2006. The control group consisted of a systematic sample of pregnant women with legal residency permit wishing to deliver at the same public hospital during the same time period. RESULTS: 161 undocumented and 233 control women were included in the study. Mean ages were 29.4 y (SD 5.8) and 31.1 y (SD 4.8) (p < 0.02), respectively. 61% of undocumented women (controls 9%) were unaware of emergency contraception (OR 15.7 (8.8;28.2) and 75% of their pregnancies were unintended (controls 21%; OR 8.0 (4.7;13.5)). Undocumented women consulted for an initial pregnancy visit more than 4 weeks later than controls and only 63% had their first visit during the first trimester (controls 96%, p < 0.001); 18% had never or more than 3 years ago a cervical smear test (controls 2%, OR 5.7 (2.0;16.5)). Lifetime exposure to violence was similar in both groups, but undocumented migrants were more exposed during their pregnancy (11% vs 1%, OR 8.6 (2.4;30.6)). Complications during pregnancy, delivery and post-partum were similar in both groups. CONCLUSION: Compared to women who are legal residents of Geneva, undocumented migrants have more unintended pregnancies and delayed prenatal care, use fewer preventive measures and are exposed to more violence during pregnancy. Not having a legal residency permit therefore suggests a particular vulnerability for pregnant women. This study underscores the need for better access to prenatal care and routine screening for violence exposure during pregnancy for undocumented migrants. Furthermore, health care systems should provide language- and culturally-appropriate education on contraception, family planning and cervical cancer screening.

Achieving energy balance at the population level through increases in physical activity.

OBJECTIVES: We estimated the amount of physical activity required for individuals to expend an additional 418.4 kJ (100 kcal) per day with the goal of achieving energy balance at the population level. METHODS: Data on total daily energy expenditures were derived from a random sample of adults residing in Geneva, Switzerland, who completed a self-administered physical activity frequency questionnaire. These data were used to simulate the effects of typical physical activity pyramid recommendations on average population energy expenditures for various activity intensities and rates of population compliance with pyramid recommendations. RESULTS: If an average 418.4 kJ (100 kcal) per day increase in energy expenditures is to be achieved, assuming 100% compliance with physical activity pyramid recommendations, the bottom tier of the pyramid must correspond to everyday activities performed at moderate to high intensity levels (e.g., moderate walking or biking). Expected population gains in energy expenditures would be only 167.4 to 251.0 kJ (40 to 60 kcal) per day at a 50% compliance rate. CONCLUSIONS: Achieving population-level energy balance through increasing energy expenditures with physical activity increases alone would require profound structural and environmental changes promoting more active lifestyles.