This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials.

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

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Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

ESPEN Guidelines on Parenteral Nutrition: intensive care.

Objective: To determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcomes. Design: Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases (PubMed, Embase, and the Cochrane controlled trials register) were searched, reference lists checked, and letters requesting details of unpublished trials and data sent to pharmaceutical companies and authors of previous trials. Main outcome measures: Anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay, and mortality. Results: Eleven studies with 837 patients met the inclusion criteria. In six studies patients in the intervention group were fed directly into the small bowel and in five studies patients were fed orally. Early feeding reduced the risk of any type of infection (relative risk 0.72, 95% confidence interval 0.54 to 0.98, P=0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33, P=0.001). Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to 1.08, P=0.080), wound infection, pneumonia, intra-abdominal abscess, and mortality, but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early (1.27, 1.01 to 1.61, P=0.046). Conclusions: There seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials. What is already known on this topic Enteral feeding within 24 hours after gastrointestinal surgery is tolerated Theoretically, early enteral feeding improves tissue healing and reduces septic complications after gastrointestinal surgery What this study adds There is no benefit in keeping patients “nil by mouth” after gastrointestinal surgery Septic complications and length of hospital stay were reduced in those patients who received early enteral feeding In patients who received early enteral feeding there were no significant reductions in incidence of anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess, and mortality

https://www.bmj.com/content/bmj/323/7316/773.full.pdf

Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials

It is commonly believed that steganography within TCP/IP is easily achieved by embedding data in header fields seemingly filled with “random” data, such as the IP identifier, TCP initial sequence number (ISN) or the least significant bit of the TCP timestamp. We show that this is not the case; these fields naturally exhibit sufficient structure and non-uniformity to be efficiently and reliably differentiated from unmodified ciphertext. Previous work on TCP/IP steganography does not take this into account and, by examining TCP/IP specifications and open source implementations, we have developed tests to detect the use of naive embedding. Finally, we describe reversible transforms that map block cipher output onto TCP ISNs, indistinguishable from those generated by Linux and OpenBSD. The techniques used can be extended to other operating systems. A message can thus be hidden so that an attacker cannot demonstrate its existence without knowing a secret key.

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Embedding covert channels into TCP/IP

We use techniques from experimental economics and psy- chology to determine how much compensation must be oered to per- suade someone to allow precise information about their location to be collected. We pretend that we are running a study that needs volunteers to have their location monitored (via their mobile phone) over a period of one month. Volunteers apply by specifying the amount of compen- sation which they would require to participate in the experiment. The experimental subjects are led to believe that we will run a sealed-bid second-price auction on these values, and thus we obtain an estimate of the value that users attach to their location data being used by third parties.

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How Much is Location Privacy Worth

In this paper we consider using client puzzles to provide incentives for users in a peer-to-peer system to behave in a uniform way. The techniques developed can be used to encourage users of a system to share content (combating the free riding problem) or perform ‘community’ tasks.

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Puzzles in P2P systems

There are many stakeholders in the production and use of Digital Rights Management (DRM) systems, and the incentives influencing their behaviour and the interactions between them are complex. In this paper I argue that it may well be more socially efficient to use market mechanisms to protect copyright holders, rather than spending large amounts of money on the development and deployment of stronger DRM mechanisms. The most publicly visible proponents of DRM systems are those whose economic rights would be protected by them. Of these, the most prominent in the media are the record and movie industry associations. The message that they seem anxious to communicate to the public is that unauthorized duplication of music tracks will destroy the industry. They conflate the effects of commercial and private copying, and most of the messages seem to portray a general nervousness reminiscent of the Y2K 'crisis'. Within the industry, though, organizations such as the British Phonographic Industry are painting a very different picture. The BPI's 'Market Information' newsletter for February 2003 put 'intense competition from other areas of the entertainment sector', and 'increasing economic uncertainty' before unauthorized copying of recorded music in the list of reasons for a drop in sales. It said further that 'despite the downturn in sales in 2002, UK record companies sustained sales of music at a very high level' and '[the market value] represents the second highest total ever achieved'. The figures also show that 'the volume of CD albums shipped in 2002 reached another all time high: 221.6m units' [4]. Given that the technology to duplicate music has been available to the consumer for many years, this hardly looks like an industry in desperate need of strong DRM protected from circumvention by legislation. A BBC News article in response to the same figures stated that 'the British record industry has experienced its biggest sales decline in decades' and that 'the BPI says piracy is the main factor' [7]. The purpose of DRM systems is to provide rights-holders with the means to control how their copyrighted materials can be used. For example, the holder of the copyright in an e-book might be able to time limit a purchaser's ability to read the book, or restrict the amount of material that can be printed out. This paves the way for far more finely grained market segmentation than is currently available in most media, and it is unclear …

Stephen Lewis

Papers

Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials

Embedding covert channels into TCP/IP

How Much is Location Privacy Worth

Puzzles in P2P systems

How Much is Stronger DRM Worth