[Meta-analysis of the effects of supplemental parenteral nutrition on prognosis of critically ill patients]

Objective: To compare the effects of supplemental parenteral nutrition (SPN) and enteral nutrition (EN) on prognosis of critically ill patients in intensive care unit (ICU) using meta-analysis. Methods: Foreign language databases including PubMed, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were retrieved with the search terms of " supplemental parenteral nutrition, parenteral nutrition, enteral nutrition, critically ill" , and Chinese database SinoMed database was retrieved with the search terms of ",,," to obtain the publicly published randomized controlled trials about the effects of SPN and EN supportive treatment on prognosis of critically ill patients in ICU from the establishment of each database to December 2018. The Google Scholar was retrieved for supplement. The outcome indexes included the infection rate, anti-infection time, antibiotic-free time, ICU overall mortality, overall mortality during hospitalization, mechanical ventilation time, length of ICU stay, and length of hospital stay. RevMan 5.3 and Stata 14.0 statistical software were used to conduct a meta-analysis of eligible studies. Results: A total of 794 patients were included in 8 studies, including 387 patients in SPN group who received SPN and EN and 407 patients in EN group who only received EN. The bias risks of the eight studies included were uncertain. Compared with that of EN group, the infection rate of patients in SPN group was significantly decreased (relative risk=0.79, 95% confidence interval=0.66-0.94, P<0.01). However, there were no statistically significant differences in ICU overall mortality, overall mortality during hospitalization, mechanical ventilation time, length of ICU stay, and length of hospital stay of patients between SPN group and EN group. The subgroup analysis showed that the risks of bias of studies and follow-up time might be sources of the heterogeneity of mechanical ventilation time. There was publication bias in ICU overall mortality (P<0.05), while no publication bias in the other outcome indexes (P>0.05). Conclusions: SPN supportive treatment can decrease the infection rate of critically ill patients in ICU, but it has no obvious influences on overall mortality, mechanical ventilation time, and length of hospital stay.

[Effect of an oral nutritional supplementation on nutritional status and quality of life in patients with colorectal cancer and postoperative adjuvant chemotherapy: A multi-center prospective randomized control trial]

Objective: To evaluate the effect of oral nutritional supplementation (ONS) on the nutritional status and quality of life in patients with colorectal cancer and postoperative adjuvant chemotherapy. Methods: This study was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-13003798). A multi-center randomized controlled trial was conducted. Colorectal cancer patients who underwent radical surgery and postoperative adjuvant chemotherapy, and had nutritional risk (nutrition risk screening 2002 score ≥3) when discharge from hospital in six hospitals (Beijing Hospital, Peking University Third Hospital, Guangzhou Nanfang Hospital, Shanghai Xinhua Hospital, Shanghai Ruijin Hospital, and Shanghai The Sixth People's Hospital) from June 2013 to August 2015 were prospectively enrolled. These patients were randomly divided into the ONS group and control group. Patients in the ONS group received dietary guidance and oral nutritional supplements (2092 kJ/day, whole protein enteral nutrition) for 90 days after discharge from hospital, while patients in the control group only received dietary guidance. Anthropometric measurements (body weight, body mass index [BMI], upper arm circumference, gripping power of the dominant hand, triceps skin fold), nutrition-related laboratory tests (hemoglobin, albumin, prealbumin, total cholesterol, triglyceride), gastrointestinal function scores and quality of life (evaluated by EuroQol five dimensions questionnaire) were collected and compared at baseline (at discharge), and at 30-day, 60-day and 90-day after discharge. Results: A total of 90 patients were included into this multi-center study, of whom 5 patients dropped out, 43 patients were assigned to the ONS group and 42 patients to the control group. Compared with baseline, the body weight of patients in the ONS group increased by (1.523±0.525) kg at 60-day and (1.967±0.661) kg at 90-day, which were significantly higher than those of patients in the control group [60-day: (-0.325±0.518) kg, P=0.015; 90-day: (-0.224±0.705) kg, P=0.027, respectively]. A similar pattern was observed for BMI, the ONS group increased by (0.552±0.203) kg/m(2) at 60-day and (0.765±0.205) kg/m(2) at 90-day, which were significantly higher than those of patients in control group [60-day: (-0.067±0.202) kg/m(2), P=0.034; 90-day: (0.022±0.210) kg/m(2), P=0.013]. No significant differences of other anthropometric measurements and nutrition-related laboratory tests were found between the two groups (all P>0.05). Furthermore, there were no significant differences of improvement in gastrointestinal function and quality of life between two groups (all P>0.05). Conclusion: Oral nutritional supplements can improve the body weight and BMI of colorectal cancer patients with nutritional risk receiving postoperative adjuvant chemotherapy, though it does not improve the quality of life.

[Dynamic investigation of nutritional risk in patients with malignant tumor during hospitalization]

Objective: To prospectively investigate the changes in nutritional status of patients with malignant tumors during hospitalization by using nutritional risk screening (NRS2002), and to analyze the correlation between the nutritional status and clinical outcomes . Methods: This was a prospective and parallel research done by multi-center collaboration from 34 hospitals in China from June to September 2014.Hospitalized patients with malignant tumors inthese departments (Department of Gastroenterology, respiratory medicine, oncology, general surgery, thoracic surgery and geriatrics)were investigated. Only the patients with age≥ 18 years and hospitalization time between 7-30 days were included. During hospitalization, the physical indexes of human bodywere measured, and the NRS 2002 scores, and monitored the nutritional support at the time points of admission and 24 hours before discharge were recorded.And whether there was a nutritional risk in hospitalized patients and its association with clinical outcomes were investigated. Results: A total of 2 402 patients with malignancies were enrolled in this study. Seventy fourpatients who did not complete NRS2002 were eliminated, and 2 328 patients were included. The number of the main diseases was the top five, including 587 cases of colorectal cancer, 567 cases of lung cancer, 564 cases of gastric cancer, 146 cases of esophageal cancer, and 119 cases of liver tumor. At the time of discharge, compared with admission, the BMI, body weight, grip and calf circumferences of patients with malignant tumor were significantly decreased (P<0.05). The total protein, albumin, prealbumin and hemoglobin were significantly lower than those at admission (P<0.05). In 2 328 patients who were completed nutritional risk screening, the rate of malnutrition at admission was 11.1% (BMI =18.5, 258/2 328) and the rate of malnutrition at discharge was 10.9% (BMI =18.5, 254/2 328), there were no significant differences (χ(2)=0.019 7, P=0.888). There were 1 204 patients with nutritional risk at admission (51.7%, NRS2002 score≥3)and 1 352 patients with nutritional risk at discharge (58.1%, NRS2002 score≥3), with significant differences (χ(2)=49.9, P<0.001). The incidence of nutritional risk in patients with colorectal, stomach, and lung tumors at discharge was significantly higher than that at admission (P<0.05). The infective complications and other complications of patients with nutritional risk were significantly greater than those without nutritional risk at admission and at discharge.ICU hospitalization stay of patients with nutritional risk was increased significantly than those without nutritional risk at admission(P=0.042). Hospitalization expenses of patients with nutritional risk was increased significantly than those of patients without nutritional risk at discharge(P<0.01). Conclusion: The patients with malignant tumor have a higher incidence rate of malnutrition at both admission and discharge and malnutritionhas correlation with adverse clinical outcomes.The aboveindicators did not improve significantly at discharge.Doctors should pay more attention to the nutritional status (screening and evaluation)of patients before discharge and use appropriate and adequate nutrition support in order to prevent the weight loss and improve the life quality of patients.

[Changes in nutritional status of patients with different diseases during hospitalization]

Objective: To evaluate changes in nutritional status of hospitalized patients with different diseases by subjective global assessment (SGA) and nutritional risk screening (NRS-2002). Methods: A prospective and parallel research done by multi-center collaboration from 34 hospitals in China from June to September 2014. Hospitalized patients with the following diseases were investigated: malignant tumor (2 487 cases), benign disease of the digestive system (1 358 cases), benign disease of the nervous system (1 043 cases), benign bone disease (451 cases), benign disease of the respiratory system(395 cases), cardiovascular disease (227 cases), benign thyroid and breast disease (179 cases), and endocrine disease (149 cases). Patients above the age of 18 and hospitalization time between 7-30 days were included. Physical indexes were measured, the NRS-2002 and SGA scores were recorded, the nutritional support were recorded during hospitalization and 24 hours after discharge from hospital. Measurement data between groups were analyzed using t test or Wilcoxon rank sum test, enumeration data and ranked data between groups were analyzed using chi-square test or Fisher exact test. Results: There were 6 638 cases of hospitalized patients, 3 861 cases were males and 2 777 were females, the male/female ratio was 1.4∶1.0; the median age was 60 years; the median height was 1.66 m; the median weight was 62 kg; the median body mass index (BMI)was 22.89 kg/m(2). At discharge, compared with that of admission, the body weight, BMI, grip strength, upper arm and calf circumferences of patients with malignant tumor were significantly decreased (t=20.15-259.67, all P<0.01); the body weight and calf circumference were significantly decreased (t=35.27, 60.40, P<0.01)of patients with digestive benign disease; the body weight of patients with benign bone diseases was decreased (t=2.12, P=0.033); the body weight, grip strength and upper arm circumference were decreased in patients with benign thyroid and breast disease (t=2.79-10.18, all P<0.01); nutritional risk incidence rate (from NRS-2002) of patients with malignant tumor was significantly higher(χ(2)=21.275, P=0.000); moderate malnutrition (from SGA) incidence rate was significantly higher(χ(2)=62.318, P=0.000; χ(2)=11.312, P<0.01) in patients with malignant tumor and with orthopedics diseases. Compared with that of admission, records of the patients with other diseases had no statistically difference at discharge, no more than 50% of the patients under risk of nutritional deficiency(except those with digestive benign diseases )received nutritional support, while the proportion of non-parenteral nutrition application was higher. Conclusion: The patients with malignant tumor have higher incidence rate of malnutrition on admission and at discharge. Doctors should pay more attention to the nutritional status(screening and evaluation) of patients before discharge and use appropriate and adequate nutrition support in order to prevent the weight loss and improve the life quality of patients.

[Complications of hyoid suspension with Repose system on obstructive sleep apnea hypopnea syndrome]

OBJECTIVE

To investigate the complications of hyoid suspension with Repose system on obstructive sleep apnea hypopnea syndrome (OSAHS) and to find out the effective prevention strategies.

METHODS

Forty four patients diagnosed by polysomnography as OSAHS were received hyoid suspension with Repose system from June 2005 to July 2009. The intraoperative and postoperative complications were analyzed retrospectively. The patients who reported abnormal swallowing were evaluated with water drinking test and video fluorography swallow study to assess biomechanical changes in swallowing.

RESULTS

Incidence rate of perioperative titanium nial amotio was 15.9% (7/44). It was avoided by implanting titanium nial again. No perioperative complications occurred such as injury of superior laryngeal nerve, blood vessel and thyrohyoid membrane, fracture of hyoid bone, suture break. All patients developed dysfunctions of pronunciation and swallowing, edema of mouth floor, dysfunctions of movement of tongue that could relieved gradually after three days on most patients. No postoperative complications occurred such as titanium nial amotio, fat liquoring, edema of mouth floor, hematoma, infection, foreign body reaction, injury of root apex of anterior tooth, dysfunctions of movement and sensation of tongue, suture break and death. All patients had over 2 year postoperative follow up. Incidence rate of dysfunctions of pronunciation and swallowing was 4.5% (2/44) and 15.9% (7/44) respectively. Main situation for dysfunctions of pronunciation was speaking ambiguity. Major manifestations of swallowing abnormalities were occasional aspiration, food going down the wrong tube, food becoming stuck in the throat, deglutition with bowing head. Seven patients who had abnormal swallowing possessed normal water drinking test and occurred asynersis of hyoid movement and laryngeal elevation, but aspiration were not observed. Three patients presented obvious stagnation in epiglottic vallecula and sinus piriformis.

CONCLUSIONS

Most complications of hyoid suspension with Repose system may be avoided or recovered on short term. Postoperative dysfunctions of pronunciation and swallowing may exist for a long time.

[Complications of tongue base reduction with radiofrequency tissue ablation on obstructive sleep apnea hypopnea syndrome]

OBJECTIVE

To investigate the complications of tongue base reduction with radiofrequency tissue ablation on patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and find out the effective prevention strategies.

METHODS

One hundred and ninety three OSAHS patients diagnosed by polysomnography were received tongue base reduction with radiofrequency tissue ablation between March 2008 and December 2009. The intraoperative and postoperative complications including bleeding, hematoma of tongue base, abscess of tongue base, altered taste, tongue numbness, deviation of tongue extension movement, dysfunctions of pronunciation and swallowing as well as the managements were analyzed retrospectively.

RESULTS

No perioperative complications occurred. There were 186 cases with postoperative pain (96.4%), 155 cases with submandibular edema (80.3%). Nocturnal sudden cardiac death was encountered in 1 case and secondary bleeding in 1 case. There was no ulceration of tongue base mucose, hematoma or abscess of tongue base, altered taste, tongue numbness, tongue deviations, speech, swallowing and taste disorder after operation. The scale of postoperative pain claimed by patients was ranged between mild to moderate. Diclofenac suppository had analgesic effect for these patients. The quantity of bleeding in patient with secondary hemorrhage was so little that after proper treatment the bleeding was stopped and never happened again. Patient with nocturnal sudden cardiac death occurred at thirty-seven hours after operation, because of swelling and pain of tongue base aggravated sleep apnea and night hypoxemia inducing fatal arrhythmia.

CONCLUSIONS

Postoperative pain and submandibular edema were 2 most common postoperative complications which can be easily controlled by antibiotics, Glucocorticoids and Diclofenac suppository. For those severe OSAHS patients accompanied by cardiopulmonary diseases, the tongue base reduction with radiofrequency tissue ablation can induce nocturnal sudden cardiac death. It is important to pay more attention on arrhythmias at night in severe OSAHS patients.

Orally delivered foot-and-mouth disease virus capsid protomer vaccine displayed on T4 bacteriophage surface: 100% protection from potency challenge in mice

An orally delivered foot-and-mouth disease (FMD) vaccine has not previously been reported. By using a T4 bacteriophage nanoparticle surface gene-protein display system (T4-S-GPDS), we created a foot-and-mouth disease virus (FMDV) entire capsid protein vaccine candidate. On the T4 phage surface SOC site, a full length FMDV capsid precursor polyprotein (P1, 755 aa) and proteinase 3C (213 aa) derived from an infected pig of serotype O strain GD-10 (1999), were separately displayed on different T4 phage particle surfaces through inserting their coding region DNAs into the T4 phage genome, yielding phage strains T4-P1 and T4-3C. We also constructed a series of FMDV sub-full length capsid structural protein (subunit) containing T4 phage recombinant vaccines. Both sucking and young BALB/c mice were used as two kinds of FMDV vaccine potency evaluation models. Many groups of both model mice were vaccinated orally or by subcutaneous injection with varying FMDV-T4 phage recombinant vaccines, with and without addition of adjuvant, then challenged with a lethal dose of cattle source virulent FMDV. In the case of immunization with a mixture of phage T4-P1 and phage T4-3C particles without any adjuvant added, all mice were 100% protected following either oral or injection immunization, whereas 100% of the control, non-immunized mice and mice immunized with only T4 phage vector Z1/Zh(-) or wild-type T4(+)D phage died; in contrast, with FMDV subunit vaccine, less than 75% protection followed the same potency challenge in both mice model groups. In addition, two pigs immunized with a phage T4-P1 and phage T4-3C mix were protected upon housing together with infected pigs. This study represents a clear example of how FMD and other pathogenic disease vaccines can be prepared by a simple and efficient bacteriophage route.

A recombinant fusion protein and DNA vaccines against foot-and-mouth disease virus type Asia 1 infection in guinea pigs

On the basis of amino acid (aa) sequence of the tandem repeat 133-158-20-34-133-158 which consisted of aa 133-158 of VP1 and aa 20-34 of VP4 of Foot-and-mouth disease virus (FMDV) type Asia 1 a recombinant prokaryotic expression vector pAS1-P encoding a fusion protein and eukaryotic expression vectors pAS1-E and pAS1-EdeltaCpG-ODN representing DNA vaccines were constructed. Guinea pigs immunized with these vaccines showed both neutralizing antibody and T cell proliferation responses. FMDV challenge tests for the first time showed that the recombinant fusion protein and pAS1-E and pAS1-EdeltaCpG-ODN vaccines protected 86%, 60% and 43% of guinea pigs from FMDV type Asia1 challenge, respectively. The results also indicated that the immune response of animals treated with the vector pAS1-E containing an oligodeoxynucleotide (ODN), which consisted of immunostimulatory cytosine-phosphate-guanosine (CpG) motifs, was augmented by CpG ODN.

[Experimental study on seal treatment of early root-surface caries in senile patients after irradiated by Nd:YAG laser]

OBJECTIVE

To study the curative effect of pulsed Nd:YAG laser on early root-surface caries in senile patients.

METHODS

Teeth with early root-surface caries removed from patients aged over 60 were irradiated with different energy output and sealant and observed under scanning electron microscope.

RESULTS

Surface layer on early root-face caries were seen to be honeycomb or nibbled before irradiation, melted after irradiated by Nd:YAG laser,and with a smooth surface of the lesion after sealed.

CONCLUSION

Early root-surface caries sealed with light-cured sealant after pulsed Nd:YAG laser irradiation is a safe and effective therapy.

The impact of alanyl-glutamine on clinical safety, nitrogen balance, intestinal permeability, and clinical outcome in postoperative patients: a randomized, double-blind, controlled study of 120 patients

PURPOSE

To evaluate the impact of alanyl-glutamine (Ala-Gln)-supplemented parenteral nutrition (PN) on clinical safety, nitrogen balance, intestinal permeability, and clinical outcome in postoperative patients.

METHODS

One hundred twenty patients undergoing major abdominal surgery were enrolled. Protocol was approved and informed consent obtained. A double-blind protocol was designed as used in Europe. The clinical safety and outcome were observed for 60 patients in 2 centers (30 each). Sixty patients from 2 additional centers (30 each) were observed for clinical safety, nitrogen balance, intestinal permeability, and clinical outcome. All patients received isonitrogenous (0.20 g/kg body wt per day) and isocaloric (30 kcal/kg body wt per day) parenteral nutrition. The study group received Ala-Gln (Dipeptiven, Fresenius Kabi, Bad Homberg, Germany) 0.50 g/kg per day. Clinical chemistry variables, plasma amino acids profile, nitrogen balance, intestinal permeability (lactulose/mannitol ratio [L/M ratio]) were measured; hospital stay and infection rate were monitored. Statview was used for analysis of variance (ANOVA) or chi2 tests. Data were expressed as means +/- SD, and the significance level was p < .05.

RESULTS

The patients in both groups were comparable prior to the operation. Vital signs and clinical chemical parameters were similar between groups. L/M ratio was 0.047+/-0.029 in control and 0.058+/-0.049 in study group before the operation (AOD-3). The L/M ratio was 0.132+/-0.081 in the control group, and 0.097+/-0.063 in study group on the seventh postoperative day. The difference of L/M ratio between groups was significant (p = .02). The cumulative nitrogen balance values were -5+/-162 mg/kg for 6 days in control and 144+/-145 mg/kg for 6 days in study group (p = .0004). All the patients recovered without incision infection. However, there were 3 cases that had infection-related complications in the control group; the difference was not significant between groups. The hospital stay in the study group was 12.5 days, which was 4 days less than that of the control group (p = .02).

CONCLUSIONS

Ala-Gln-supplemented PN was clinically safe, had better nitrogen balance, and maintained intestinal permeability in postoperative patients. The clinical outcome of the patients in study group was better; it was significantly different from the control group.

Severe occlusive carotid artery disease: hemodynamic assessment by MR perfusion imaging in symptomatic patients

BACKGROUND AND PURPOSE

Cerebral hemodynamic status has been reported to influence the occurrence and outcome of acute stroke. The purpose of this study was to assess hemodynamic compromise in symptomatic patients with severe occlusive disease of the carotid artery by the use of echo-planar perfusion imaging.

METHODS

Spin-echo echo-planar perfusion imaging was performed in 11 patients (two had bilateral disease) with severe stenosis or occlusion of the carotid artery who had experienced either a recent transient ischemic attack or minor stroke. Relative cerebral blood volume (rCBV) maps and relative mean transit time (rMTT) maps were generated from the time-concentration curve. Findings on T2-weighted images, angiograms, rCBV maps, and rMTT maps were compared and assessed qualitatively and quantitatively.

RESULTS

Although the abnormalities on T2-weighted images were absent, minimal, and/or unrelated to the degree of stenosis or collateral circulation, rMTT maps showed much larger and more distinct perfusion abnormalities along the vascular distribution of the affected vessels in all 13 vascular territories of the 11 patients. Despite obvious abnormalities on rMTT maps, none of the patients had evidence of decreased rCBV in the affected brain tissue (increased in three, normal in eight). A statistically significant difference in rMTT values was found between the affected and unaffected brain tissue, whereas no significant difference was seen in rCBV values.

CONCLUSION

Echo-planar perfusion imaging is a noninvasive and rapid method for evaluating the hemodynamics in severe occlusive carotid artery disease and the compensatory vascular changes, and it may be useful in patient management.

Application of contrast agents in the evaluation of stroke: conventional MR and echo-planar MR imaging

The availability of new therapeutic interventions, including neuroprotective agents and endovascular thrombolysis, has given new hope to patients suffering an acute stroke. Early intervention remains a key factor in the effectiveness of these new and traditional treatments. More importantly, the capability to assess the viability and reversibility of the ischemic tissue became essential for better delineation and differentiation of infarcted versus ischemic tissue and patient management. Abnormal MR imaging (MRI) findings during acute stroke usually reflect the underlying pathophysiologic changes, which can be classified into three sequential stages: (a) hypoperfusion, (b) cellular dysfunction and (c) breakdown of the blood-brain barrier. The first stage is a kinetic phenomenon (not biologic) and, therefore, can be detected immediately. Contrast agents accentuate the abnormal flow kinetics and facilitate the early diagnosis of ischemia using either conventional MRI or newly developed echo-planar perfusion imaging (EPPI). The demonstration of abnormal arterial or parenchymal enhancement on conventional MRI during acute stroke provides the earliest sign of vascular occlusion/stenosis. EPPI, in contrast, provides information related to microcirculation (< 100 microns) and tissue reserve (cerebral blood volume) that cannot be obtained by conventional angiography and is directly related to the target end-organ. Further information obtained from both contrast MRI and EPPI may have a predictive value in the clinical outcome of acute stroke patients.