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Bioelectrical impedance analysis--part I: review of principles and methods.

It has become increasingly clear that life-history patterns among the vertebrates have been shaped by the plethora and variety of immunological risks associated with parasitic faunas in their environments. Immunological competence could very well be the most important determinant of life-time reproductive success and fitness for many species. It is generally assumed by evolutionary ecologists that providing immunological defences to minimise such risks to the host is costly in terms of necessitating trade-offs with other nutrient-demanding processes such as growth, reproduction, and thermoregulation. Studies devoted to providing assessments of such costs and how they may force evolutionary trade-offs among life-history characters are few, especially for wild vertebrate species, and their results are widely scattered throughout the literature. In this paper we attempt to review this literature to obtain a better understanding of energetic and nutritional costs for maintaining a normal immune system and examine how costly it might be for a host who is forced to up-regulate its immunological defence mechanisms. The significance of these various costs to ecology and life history trade-offs among the vertebrates is explored. It is concluded that sufficient evidence exists to support the primary assumption that immunological defences are costly to the vertebrate host.

https://www.jstor.org/stable/pdfplus/3546398.pdf

Trade‐offs in evolutionary immunology: just what is the cost of immunity?

Bioelectrical impedance analysis-part II: utilization in clinical practice.

Systematic literature reviews including meta-analyses are invaluable scientific activities. The rationale for such reviews is well established. Health care providers, researchers, and policy makers are inundated with unmanageable amounts of information; they need systematic reviews to efficiently integrate existing information and provide data for rational decision making. Systematic reviews establish whether scientific findings are consistent and can be generalised across populations, settings, and treatment variations, or whether findings vary significantly by particular subsets. Meta-analyses in particular can increase power and precision of estimates of treatment effects and exposure risks. Finally explicit methods used in systematic reviews limit bias and, hopefully, will improve reliability and accuracy of conclusions.

Systematic literature review is a fundamental scientific activity. Its rationale is grounded firmly in several premises. Firstly, large quantities of information must be reduced into palatable pieces for digestion. Over two million articles are published annually in the biomedical literature in over 20 000 journals1 - literally a small mountain of information. For example, about 4400 pages were devoted to approximately 1100 articles in the BMJ and New England Journal of Medicine, combined, in 1992. In a stack, two million such articles would rise 500 m. Clearly, systematic literature review is needed to refine these unmanageable amounts of information. Through critical exploration, evaluation, and synthesis the systematic review separates the insignificant, unsound, or redundant deadwood in the medical literature from the salient and critical studies that are worthy of reflection.2

Secondly, various decision makers need to integrate the critical pieces of available biomedical information. Systematic reviews are used by more specialised integrators, such as economic and decision analysts, to estimate the variables and outcomes that are included in their evaluations. Both systematic and more specialised integrations are used by clinicians to keep abreast of the primary literature in a given field …

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Rationale for systematic reviews.

OBJECTIVE: To better understand the absolute and relative risks of bloodstream infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults in which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI. METHODS: English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremia [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream infection AND the specific type of intravascular device (eg, central venous port). Mean rates of IVDrelated BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days. RESULTS: Point incidence rates of IVD-related BSI were lowest with peripheral intravenous catheters (0.1%, 0.5 per 1000 IVDdays) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the intensive care unit. Surgically implanted long-term central venous devices—cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)—appear to have high rates of infection when risk is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodialysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI. CONCLUSIONS: Expressing risk of IVD-related BSI per 1000 IVDdays rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies in which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs in use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related infection have focused on short-term noncuffed CVCs used in intensive care units, infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

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The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies

Home parenteral nutrition in the United Kingdom and Ireland.

Following laparotomy for severe intra-abdominal sepsis, the abdominal cavity was left open to heal by granulation in 18 patients. In 14 patients, operation was required because of recurrent gastrointestinal perforation or anastomotic dehiscence. In three, the indication for this procedure was recurrent pancreatic abscess. Of the 17, 13 had previously undergone multiple operations which had failed to control sepsis. Laparostomy was performed as a primary procedure in only one case, a patient with fulminating pancreatitis requiring pancreatic necrosectomy. All patients received parenteral nutrition. The overall mortality was 28 per cent. However, there was only one death among the last 9 patients treated compared with 4 in the previous 9. The median sepsis score in the first 9 (19, range 10-26) was not significantly different (P greater than 0.05) from that in the subsequent 9 patients (17, range 8-21). Three of the four who had initially presented with severe acute pancreatitis died. No patient eviscerated and only 9 (50 per cent) required mechanical ventilation for a median duration of 5 days. The median time for wound healing was 10 weeks and 6 patients have subsequently undergone definitive surgery with satisfactory results. Laparostomy is a valuable technique in the management of severe, intractable intra-abdominal sepsis.

'Laparostomy': a technique for the management of intractable intra-abdominal sepsis.

Although nutritional support is vital to treatment of severe sepsis, the septic patient does not respond normally to glucose infusion. We have used the hyperglycemic glucose clamp technique to investigate the initial hormonal and metabolic responses of the septic patient to glucose under controlled conditions. The plasma glucose concentration was raised to and maintained at 12 mmol/liter for 2 hr in 12 septic patients and 11 normal controls. Glucose utilization, assessed from the amount infused, was significantly depressed in the patients, despite similar plasma insulin concentrations in the two groups. Forearm glucose uptake was similarly impaired. Despite very similar plasma free fatty acid concentrations in the two groups, which were suppressed equally by the glucose infusion, whole-body fat oxidation was elevated in the patients compared with the controls, and suppressed to a lesser extent in response to glucose. Glycerol and ketone body concentrations were elevated in the patients in keeping with a p...

Hormonal and Metabolic Responses to Glucose Infusion in Sepsis Studied by the Hyperglycemic Glucose Clamp Technique

An economic evaluation of home parenteral nutrition (HPN) for intestinal failure is presented. The cost-utility of HPN and factors affecting the cost-utility ratio were examined to determine whether current practice is the most efficient way of treating intestinal failure. Quality-adjusted life-years (QALYs) gained were measured using a validated health status questionnaire. The cost of treating a patient with intestinal failure was calculated, and marginal cost per QALY gained ratios were obtained. The cost per QALY for an average patient was approximately £68 975, but the value for patients over 55 years of age of about £126 865 compared with approximately £58 233 for those under 44 years. Treating a patient in hospital rather than at home increased the estimated cost per QALY to approximately £190 000. The current practice of home care is about 65 per cent more cost-effective than hospital care.

Cost–utility analysis of home parenteral nutrition

1. Thigh muscle samples for analysis were obtained from 35 control subjects and 12 severely ill patients, of whom five had disease-induced undernutrition and seven had associated sepsis. An improvement in the Bergstrom technique for analysing muscle needle biopsy samples was used. 2. Muscle water, chloride and DNA were increased in both groups of ill patients, indicating an increase in the extracellular component and loss of muscle protein. 3. Falls in the concentrations of glutamine, glutamate, arginine, histidine, ornithine and lysine and rises in those of glycine, serine, asparagine, tyrosine, valine, leucine, isoleucine, phenylalanine, methionine and tryptophan were observed in the group of ill patients compared with those in the control subjects. The changes were present mainly in the patients with sepsis, significant differences between these and the undernourished ones without associated sepsis being observed in glutamine, lysine, tyrosine, valine, leucine, isoleucine, phenylalanine and methionine. The changes were either absent or slight in plasma. 4. The increased concentrations observed in six essential amino acids in the septic patients, but not in those with undernutrition, is consistent with the increased catabolic rate of sepsis. 5. However, the branched-chain amino acids, and lysine, threonine, arginine, and histidine, were present in lower concentrations than might be expected from catabolism, presumably due to utilization. It is suggested therefore that septic patients might benefit from increased proportions of these amino acids in their feeding regimen.

Miles Irving

Papers

Home parenteral nutrition in the United Kingdom and Ireland.

'Laparostomy': a technique for the management of intractable intra-abdominal sepsis.

Hormonal and Metabolic Responses to Glucose Infusion in Sepsis Studied by the Hyperglycemic Glucose Clamp Technique

Cost–utility analysis of home parenteral nutrition

Intracellular Free Amino Acids in Undernourished Patients with or without Sepsis