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Glucose control The survival benefit of tight glucose control TGC target 4.

The intensive care medicine research agenda in nutrition and metabolism

The observed differences in outcome may be related to different targets achieved, different blood glucose analyzing methodology, or the difference in the amount and route of early nutritional intake between the Leuven as compared to the other trials [ 36 , 38 ].

A study found that markers of inflammation, endothelial injury, and coagulation activation were attenuated in the patients with stress hyperglycemia without diabetes but not in diabetics, suggesting different underlying pathophysiology. These hypothesis-generating findings are yet to be examined in RCTs. Remaining areas of uncertainty As indicated above, recent trials have highlighted many areas of uncertainty in critical care nutrition.

Evaluation of energy expenditure and monitoring of nutritional effects in different phases of critical illness and across patients with different nutritional risks 1. Method of administration of enteral and parenteral nutrition 2.

Substrate requirements: proteins, carbohydrates, and micronutrients 3.

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Nutrition and functional recovery 4. Management of intestinal and gastric feeding intolerance 5. Immune-modulating nutrition 6. Glucose control 7. Should glucose targets differ according to previous glycemic control in patients with pre-existing diabetes?


Evaluation of EE and monitoring of nutritional effects in different phases of critical illness and across patients with different nutritional risks Indirect calorimetry is considered the gold standard in measuring EE in clinical settings [ 39 ] and is recommended, when available, by clinical practice guidelines, although it is acknowledged that the evidence on which this premise is based is limited [ 5 , 40 ]. Nevertheless, measuring EE might have a role in preventing overfeeding.

Predictive equations are often used instead of direct EE measurement but may over- or underestimate EE and do not account for the variation of EE during critical illness over time [ 3 ].

As in clinical practice, most major studies including targeted feeding in the design rely on these predicted values of EE. A more fundamental question is whether calories delivered to patients during the acute phase of their critical illness should match measured or estimated EE despite ongoing endogenous nutrient release, which is not suppressed by feeding and is unmeasurable [ 41 ].

In animal models and in healthy volunteers, data suggest that protein synthesis is significantly greater after the consumption of a single bolus dose of whey protein than when the whey protein was given as small-pulsed drinks or as a continuous infusion [ 42 , 43 , 44 ]. Intermittent feeding may also have greater anabolic response, increased gastric contractility and emptying, as well as less diarrhea and better absorption owing to slowing of intestinal transit from increased peptide YY release [ 45 , 46 ].

However, clinical data supporting this practice are awaited. In another study, the administration of amino acids at either 0. The interpretation of these improvements was somewhat complicated by the higher mortality potentially competing with weakness in the patients receiving more amino acids [ 49 ].

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There is evidence to suggest that if a basal amount of protein is provided, varying the percentage of goal calories delivered may not change outcome. In the PermiT trial [ 8 ] and other studies [ 50 ], restricting calories did not change outcome compared to full feeds when protein provision was equal between groups.

Another study showed increased survival with achievement of protein intake of 1. An earlier small RCT showed that higher protein delivery at 1.

Not all proteins are equivalent in their ability to stimulate protein synthesis; whey protein high in leucine may increase muscle synthesis compared to soy or casein protein [ 42 ]. An RCT in obese older adults showed that a high whey protein-, leucine-, and vitamin D-enriched supplement compared with isocaloric control preserves appendicular muscle mass during hypocaloric feeding and resistance exercise program [ 54 ]. The implications for critically ill patients are unknown and require further study.

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Brinkmann5 and M. The X-ray continuum spectrum can be described by the sum of a power law with photon index 6 and a soft emission component characterized by a blackbody with temperature 29 6 2 eV.

The total luminosity of the soft component is larger than that of the power-law component if the power law is cut off around a few hundred keV. The X-ray flux showed a 47 per cent increase between two ASCA observations 4 months apart, but no spectral variability was seen. We argue that reprocessing of the hard X-ray emission cannot produce all the soft X-ray emission, since the total luminosity of the soft component is larger than that of the integrated power-law component.

Similarities with some stellar black hole candidates are briefly discussed. Key words: galaxies: individual: RX J This energies from 2 keV to a few tens of keV the intrinsic spectrum is spectrum is similar to that of Galactic black hole candidates in the described by a hard power-law component with a mean photon high state e.

Tanaka Therefore, these authors postulate index of 1.

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This component is thought to originate from Comp- black hole analogues of Galactic black hole candidates in the high tonization of soft photons in a tenuous hot gas, possibly in an state. Matsuoka et al. While disc in these objects to date e. Tanaka et al. The most extreme soft X-ray excess Sy1s are the observation of this object was performed in In this ray photon indices of these objects are usually G,3—5 for a power- paper, we describe the analysis of the pointed ROSAT observation as law description.

The optical spectra of these objects usually show well as two ASCA observations.

The observations and data reduc- narrow emission-line profiles in line with the anti-correlation tion methods are described in Section 2.

The results of the spectral between the emission-line width and soft X-ray spectral index analysis are presented in Section 3. Wang et al. Table 1.

The source photons of the Seyfert GIS3 We restricted the PSPC spectrum to the 0. The 2 keV energy band.

The two methods gave very similar results and source did not vary within individual observations, but a 47 per cent we will refer only to the latter one.

PSPC image. This value is circular region centred on the Seyfert galaxy with a radius of 3.

The background was estimated from an annular source-free if we consider the quoted error of about 20—30 per cent in region. The spectrum was corrected for vignetting and deadtime, their data base. No significant column density in the direction of this source. When NH is fixed at variations in the source count rate were detected over the , s this Galactic value, a single power law yields a relatively poor fit ROSAT observation spanning about one day.

A better fit for the single-power-law February Table 1. No risetime correction was applied to the GIS data.

The a power-law photon index 2. This indicates that the single-power-law Standard data selection criteria were applied, the most relevant being model does not correctly describe the ROSAT data.

Therefore have elevation and bright Earth angles greater than 58 and for GIS and we tried more complicated models.

Table 2.Wang et al. Therefore, these authors postulate index of 1. T Tuner pdf manual download. Check out actual user reviews here. Wiley, Chichester. Tanaka et al. Weron, R. Books by Language.

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