Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial.

BACKGROUND: Nutritional support in patients with cancer aims at improving quality of life. Whether use of nutritional support is also effective in improving clinical outcomes requires further study. PATIENTS AND METHODS: In this preplanned secondary analysis of patients with cancer included in a prospective, randomized-controlled, Swiss, multicenter trial (EFFORT), we compared protocol-guided individualized nutritional support (intervention group) to standard hospital food (control group) regarding mortality at 30-day (primary endpoint) and other clinical outcomes. RESULTS: We analyzed 506 patients with a main admission diagnosis of cancer, including lung cancer (n = 113), gastrointestinal tumors (n = 84), hematological malignancies (n = 108) and other types of cancer (n = 201). Nutritional risk based on Nutritional Risk Screening (NRS 2002) was an independent predictor for mortality over 180 days with an (age-, sex-, center-, type of cancer-, tumor activity- and treatment-) adjusted hazard ratio of 1.29 (95% CI 1.09-1.54; P = 0.004) per point increase in NRS. In the 30-day follow-up period, 50 patients (19.9%) died in the control group compared to 36 (14.1%) in the intervention group resulting in an adjusted odds ratio of 0.57 (95% CI 0.35-0.94; P = 0.027). Interaction tests did not show significant differences in mortality across the cancer type subgroups. Nutritional support also significantly improved functional outcomes and quality of life measures. CONCLUSIONS: Compared to usual hospital nutrition without nutrition support, individualized nutritional support reduced the risk of mortality and improved functional and quality of life outcomes in cancer patients with increased nutritional risk. These data further support the inclusion of nutritional care in cancer management guidelines.

Clinical risk scores and blood biomarkers as predictors of long-term outcome in patients with community-acquired pneumonia: a 6-year prospective follow-up study.

OBJECTIVE: Prediction of long-term outcomes in patients with community-acquired pneumonia (CAP) is incompletely understood. We investigated the value of clinical risk scores [pneumonia severity index (PSI) and CURB-65] (Confusion, Urea, Respiratory rate, Blood Pressure, Age >65 years) and blood biomarkers of different physiopathological pathways in predicting long-term survival in a well-characterized cohort of patients with CAP enrolled in an antibiotic stewardship trial. DESIGN, SETTING AND SUBJECTS: Patients admitted with CAP to six medical centres in Switzerland were prospectively followed for 6 years. Cox regression models and area under the receiver operating characteristics curve (AUC) were used to investigate associations between initial risk assessment and all-cause mortality. MAIN OUTCOME MEASURE: All-cause mortality during a 6-year follow-up period. RESULTS: Six-year mortality in the present cohort (median age 73 years) was 45.1% [95% confidence interval (CI) 41.8-48.3%]. Initial PSI and CURB-65 scores both had excellent long-term prognostic accuracy, with a stepwise increase in mortality per risk class. The hazard ratios (95% CI) of the highest PSI and CURB-65 classes (reference: lowest class) were 38.0 (14.0-103.0) and 7.8 (2.2-14.5), respectively, after 6 years. The addition of inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers measured upon hospital admission further improved the prognostic capabilities of the PSI (AUC increase from 0.79 to 0.83; P < 0.0001) and the CURB-65 score (AUC increase from 0.73 to 0.80; P < 0.001). CONCLUSION: Risk assessment using clinical scores allowed accurate long-term prognostication, which was further improved by the addition of two inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers. These data provide a rationale for a more risk-adapted, 'personalized' strategy for long-term management of patients with CAP.

Evaluation of an algorithm for intensive subcutaneous insulin therapy in noncritically ill hospitalised patients with hyperglycaemia in a randomised controlled trial.

BACKGROUND: Currently glycaemic targets of <7.8 mmol/l without hypoglycaemia are recommended for diabetic patients on general wards before meals. Efficient and safe strategies to achieve these targets with subcutaneous insulin injections outside the intensive care setting are not well established. The aim of this trial was to evaluate a subcutaneous insulin algorithm, which incorporates insulin resistance due to individual features and acute illness, for correction of hyperglycaemia in general medical wards. METHODS: This was a two-centre, randomised controlled trial in two Swiss hospitals. Patients with initial plasma glucose levels >8 mmol/l were randomised to either an intervention group or a control group. The primary endpoint was the time in the glycaemic target range (5.5-7.0 mmol/l) within the first 48 hours. RESULTS: Patients in the intervention group (n = 67) had significantly lower plasma glucose levels during the first 48 hours as compared with control patients (n = 63) (7.7 ± 3.0 mmol/l; mean ± standard deviation [SD]) vs 9.7 ± 3.9 mmol/l, p <0.0001). The intervention group reached the glycaemic target range earlier (median 9.5 vs 24.0 hours, p <0.0001) and remained longer in this range (difference: 9.5 hours, 95% confidence interval [CI] 5.1, 13.9). There were more episodes of mild hypoglycaemia in the intervention group (19.4% vs 6.3%, absolute difference 13.5%, 95%CI 1.8, 24.3), with no difference in rates of severe hypoglycaemia. CONCLUSIONS: Incorporation of insulin resistance factors into a subcutaneous insulin algorithm achieved early and sustained glycaemic control in noncritically ill patients admitted to general medical wards without apparent safety concerns. The overall clinical benefit of this strategy remains to be determined.

Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance.

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 µg/L and +31 % if PCT > 0.25 µg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 µg/L and +13 % if PCT > 0.25 µg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 µg/L and +19 % if PCT > 0.25 µg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

Combined ultramicrotomy for AFM and TEM using a novel sample holder.

A new sample holder that allows combined microtomy for atomic force microscopy (AFM) and transmission electron microscopy (TEM) is described. The main feature of this sample holder is a small central part holding the sample. This central part fits into the head of an atomic force microscope. AFM measurements can be performed with a sample mounted in this central part of the sample holder. This makes the alignment of a microtomed bulk sample unnecessary, and offers the opportunity of an easy and fast combined sample preparation for AFM and TEM.

Modeling organic chemical fate in aquatic systems: significance of bioaccumulation and relevant time-space scales.

The importance of aquatic food chain bioaccumulation of organic chemicals in contributing to human dose is derived. It is shown that for chemicals with log octanol water partition coefficients greater than about 3, the role of food chain transfer to fish consumed by humans becomes the more dominant route over drinking water. Modeling of aquatic food chain bioaccumulation then becomes necessary to accurately estimate dose of such chemicals to humans. The relevant time and space scales for groundwater and surface water also indicate a division of organic chemicals at a log octanol water partition coefficient of about 3. For chemicals greater than that level, groundwater transport is minimal, while for chemicals with log octanol water coefficients of less than about 3, detention times are long relative to surface water and biodegradation processes become more significant. An illustration is given of modeling the groundwater transport of two organic chemicals (BCEE and benzene) and a metal (chromium) at a Superfund site. The model indicates that after 10 years only a relatively small fraction of the chemicals had traveled in the groundwater about 300 m to the point of release from the site to surface water. On the other hand, steady state in the adjacent stream and lake is reached rapidly over a distance of 2000 m, illustrating the difference in spatial and temporal scales for the groundwater and surface water.

Development of a pharmacokinetic model for chromium in the rat following subchronic exposure. I. The importance of incorporating long-term storage compartment.

A pharmacokinetic model of chromium depuration in the rat has been developed under subchronic exposure conditions. Rats were exposed to 100 ppm Cr(VI) in their drinking water for 6 weeks, followed by a 140-day period of depuration. Tissue concentrations of Cr at the end of the 6-week exposure period were greatest in the bone, spleen, and kidney, with lower concentrations present in the liver and blood. The overall kinetics of Cr depuration from the tissues were relatively slow, especially for the largest compartment which included bone. The results indicated that the half-life of Cr in bone exceeded 100 days. A three-compartment model was developed to fit the data. Liver, kidney, and spleen were grouped into a single compartment which was linked to a major storage compartment (i.e., bone, skin, hair, and muscle) via the blood. Using this model, the time to a 50% reduction of whole body Cr (i.e., loss of total Cr mass for the whole rat) was calculated to be about 80 days. The higher half-life for the storage compartment of 100 days is due to the relative weights of the compartments and the more rapid loss of Cr from the liver, kidney, and spleen compartment. The data suggest that Cr may be sequestered and release of Cr by the storage compartment over an extended period of time, thereby, may play an important role in maintaining elevated body burdens and tissue concentrations of Cr following long-term exposure to this toxic metal.

Effect of age on D2 dopamine receptors in normal human brain measured by positron emission tomography and 11C-raclopride.

Human postmortem and animal experimental results suggest a decline of the cerebral dopaminergic neuronal system with age. In this study, the radiotracer carbon 11-labeled-raclopride and positron emission tomography were applied to determine the effect of age on striatal D2 dopamine receptors in 32 healthy volunteer subjects (age range, 21 to 68 years; median, 31 years). An index of specific 11C-raclopride binding was calculated for putamen, caudate nucleus, and other brain regions in each subject. A significant decrease with age of the index for specific tracer uptake was found in putamen and caudate nucleus. The decrease was steep until 30 years, but slower afterward. After approximately 30 years of age, the decline of specific 11C-raclopride binding in putamen was found to be 0.6% per year. Our results suggest that D2 dopamine receptor binding sites (mainly postsynaptically located) decrease as a consequence of normal aging in parallel with the decline of the presynaptic nigrostriatal dopaminergic neuronal system.

Savoxepine: striatal dopamine-D2 receptor occupancy in human volunteers measured using positron emission tomography (PET).

The extent and duration of striatal dopamine-D2 receptor occupancy by savoxepine in humans has been studied using positron emission tomography with [11C]-raclopride, in order to investigate why the anticipated favourable ratio between its extrapyramidal and antipsychotic effects was not achieved in practice. After 0.25 mg savoxepine, striatal D2 receptor occupancy peaked at 50-60% after 24-36 h and disappeared within 6 days. After doses of 0.1 mg to 0.5 mg, D2 receptor occupancy in the putamen and caudate nucleus increased from 20 to 70% 3-7 h after administration and amounted to 40 to 75% at the peak time (20-29 h). This suggests that cumulative D2 receptor blockade would occur if equal or increasing doses of savoxepine were given repeatedly. Extrapyramidal adverse-effects would be likely to occur under such circumstances. An adequate test of the theory that preference for hippocampal dopamine D2 receptors with afford a good therapeutic ratio requires an alternative dosing regimen.

[High pressure extraction of marjoram. 1. Sensory characterization of marjoram oleoresin by profile analysis]. / Hochdruckextraktion von Majoran. 1. Mitt. Sensorische Charakterisierung von Majoranoleoresin mittels Profilanalyse.

A flavour profile analysis has been developed for the evaluation of carbon dioxide extracts of marjoram. On the basis of the commercial quality of various proveniences of marjoram a first flavour profile was established. Components which decisively influence the flavour were examined for the determination of relevance factors. The taste profile is the basis for the calculation of the quality coefficient as measure of the sensory quality. The expert profile as a theoretical model is based on optimum intensities of individual taste components. Differences from the expert profile are considered by corrected intensities and lead to a decrease of the quality coefficient. The method used for the development of a high pressure extraction technology is quite suitable for the characterization of marjoram extracts as well as for the evaluation of commercial marjoram samples.

A therapeutic approach and objective test in the treatment of tremor.

Medical treatment of tremor is deceptive. The biochemical disturbance causing its appearance is not known, so that no specific treatment can be applied. Many substances have been proposed for their antitremulant properties, but clinical results must be interpreted with caution as tremor is a labile symptom which is under many influences. The authors have analysed the clinical effect of an interesting antitremulant drug and have reported an original method for measuring tremor.