Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.
Left ventricular (LV) volumes obtained from RT3DEdatasets are underestimated compared to cardiac magnetic resonance (CMR). We sought to study the accuracy and reproducibility of this technique in a multicenter setting, the inter-institutional differences in these variables in relationship with investigators' experience, and the potential sources of underestimation. 92 patients underwent CMR and RT3DE imaging at 4 different institutions. ESV: r=0.93), but were 29 and 26% lower. This finding was consistent across participating institutions, with the magnitude of bias being related to experience. Exclusion of trabeculae and mitral valve plane from the CMR reference essentially eliminated the inter-modality bias. In conclusion, LV volumes are underestimated in most patients because RT3DE imaging cannot differentiate between the myocardium and trabeculae. IntroductionThe superiority of 3D measurements of LV volume measurements based on endocardial surface detection [1,2] was recently demonstrated for RT3DE imaging in terms of improved accuracy [3,4] and reproducibility of [2,4]. Although this methodology has been compared against CMR in single center studies, it has not been validated in a standardized protocol in a multicenter setting. Importantly, several recent studies have reported that RT3DE underestimates LV volumes [2,5] to a variable extent, but no consensus has been reached regarding the factors contributing towards this error. We hypothesized that this underestimation may be due to differences in spatial and contrast resolution between RT3DE and CMR imaging that determine the level of detail with which the LV endocardial surface is visualized. Also, the inter-modality discordance may be increased by analysis related differences.This study was designed to: (1) validate volumetric analysis of the left ventricle from RT3DE datasets against the standard CMR reference technique in a multicenter setting, (2) compare the reproducibility of this analysis with CMR measurements, (3) study inter-institutional differences in accuracy and reproducibility of the RT3DE volume measurements in relationship with the level of the investigators' experience, and (4) to identify and evaluate the relative contributions of the potential sources of error. Methods Study designInitially, aim 1, i.e. the accuracy of RT3DE volume measurements, was addressed by analyzing RT3DE and CMR images obtained in a large group of patients and comparing ESV and EDV between the two modalities. Aim 2, i.e. the reproducibility of both techniques, was achieved using repeated measurements.To achieve aim 3, i.e. the experience-related interinstitutional differences, investigators in the participating institutions, were given different levels of instruction and training with the prototype software (QLAB, 3DQ-Advanced, Philips). The investigators were not informed that the level of experience was part of the study design. Accuracy and reproducibility were compared between institutions and correlated with the level of experience.To achieve aim 4, i.e. iden...
HighlightsDifferent methanogenic communities in mesophilic and thermophilic reactors.High VFA levels do not cause major changes in archaeal communities.Real-time PCR indicated greater diversity than ANAEROCHIP microarray.
Aims The aim of this study was to determine whether intermittent ambulatory treatment with levosimendan would improve functional capacity, quality of life, and event‐free survival in patients with advanced heart failure. Methods and results This was a prospective, randomized, double‐blind, placebo‐controlled, multicentre, parallel‐group trial of pulsed infusions of levosimendan in 120 outpatients with advanced heart failure (EF ≤35%, NYHA class III or IV). The study was conducted at 11 centres in Austria, Greece, and Germany. Levosimendan (0.2 µg/kg/min) or placebo was administered for 6 h at 2‐week intervals over 6 weeks, in addition to standard care therapy. The primary outcome was the proportion of patients with a ≥20% improvement in the 6 min walk test and a ≥15% score increase on the Kansas City Cardiomyopathy Questionnaire at the end of the 24‐week study period. Secondary outcomes included event‐free survival after 24 weeks. Analyses were performed on an intention‐to‐treat basis. The primary endpoint was reached in 19% of patients receiving levosimendan and 15.8% of patients receiving placebo (odds ratio 1.25; 95% confidence interval 0.44–3.59; P = 0.810). Cardiac death (four vs. one), heart transplants (two vs. one), and acute heart failure (14 vs. nine) were more frequent with placebo as compared with levosimendan. The incidence of side effects was comparable between groups. Conclusion Intermittent ambulatory treatment with levosimendan in patients with advanced heart failure did not improve significantly functional capacity or quality of life as compared with placebo. An adequately powered, event‐driven trial is warranted to enlarge on our findings. Trial registration: NCT01065194.
Volumetric quantification of RV volume was performed on CMR, CCT, and RT3DE images. Eliminating analysis-related intermodality differences allowed fair comparisons and highlighted the unique limitations of each modality. Understanding these differences promises to aid in the functional assessment of the RV.
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