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PubMed2006

Impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines: a multilevel analysis.

The authors assessed the relative impact of structural and social influence interventions on reducing sexually transmitted infections (STIs) and HIV risk behavior among female sex workers in the Philippines (N = 897). Four conditions included manager influence, peer influence, combined manager-peer influence, and control. Intervention effects were assessed at the establishment level in multilevel models because of statistical dependencies among women employed within the same establishments. Control group membership predicted greater perceived risk, less condom use, less HIV/AIDS knowledge, and more negative condom attitudes. Combination participants reported more positive condom attitudes, more establishment policies favoring condom use, and fewer STIs. Manager-only participants reported fewer STIs, lower condom attitudes, less knowledge, and higher perceived risk than peer-only participants. Because interventions were implemented at the city level, baseline and follow-up city differences were analyzed to rule out intervention effects due to preexisting differences.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Physicians and the pharmaceutical industry: a dysfunctional relationship.

The pharmaceutical industry is one of the largest and most profitable industries in the world, and in the United States, the industry has a particularly privileged economic position. Yet the cost of drugs in the United States is higher than anywhere else, due largely to the fact that the industry is focusing increasingly on marketing rather than on the development of meaningful new medications: available evidence does not support claims of great expense for the development of new drugs. Because of its vast resources, the pharmaceutical industry has assumed an increasing influence in medicine, which, given the differences in values and priorities between medicine and the drug companies, is a cause for concern. The pharmaceutical industry has acted to maximize its profits in ways that frequently conflict with medicine's need for truth and full disclosure. Indeed, the industry has arguably worked to compromise physicians' judgments, as well as academic standards. As a result, despite government regulation there have been unnecessary adverse effects from drugs. The experience with butorphanol (Stadol) exemplifies problems in the current system and the harm that can result. Changes are suggested to make the pharmaceutical industry more responsive to the needs of patients and physicians.

Adverse Drug Reaction Reporting Systems↗
PubMed1998

[Self-mutilating hand and finger injuries among physicians suspected of insurance fraud].

27 cases of questionable self-mutilation among physicians (concerning finger and hand injuries) were analyzed retrospectively. The evaluation based on files of the insurance companies, reconstructive examinations and experimental investigations. Three typical cases are described in detail, the "victims" were suspected to have committed a special kind of fraud in order to claim financial compensation from their accident-insurance companies; the contract included special invalidity payments for finger injures (so-called "Gliedertaxe"). Many of these physicians had worked in the surgical field: apart from one 38-year-old female all of them were males, aged between 41 and 66 years. The mutilating instruments were often circular saws, sometimes chain saws and a great variety of other tools, for example hatchet, big scissors and other sharp instruments. By means of forensic-medical expertise and criminalistic investigations the insurance companies were able to demonstrate clearly that the amputation was voluntarily self-inflicted. The forensic-medical argumentation concerning intentional self-mutilation included the so-called execution position of the finger, the injury pattern, the investigations of blood stains and ergonometric aspects.

Adult↗
PubMed1982

Teacher popularity and contrast effects in a classroom token economy.

There is a common fear that the use of a token economy in one classroom might harm pupil performance in situations where the contingencies are not in effect. This study investigated potential contrast effects on measures of children's productivity and attitudes toward teachers. Six children with reading deficits participated. A multiple baseline design was used to assess the effects of a token economy which was systematically introduced across three teachers. Dependent measures included two rating forms of teacher popularity and work rate on a programmed reading series. The results indicated that the token system was effective in increasing the children's productivity and that no consistent behavioral contrast effects occurred. Furthermore, children's attitudes toward teachers did not appear to be influenced by the token economy until only one teacher was not delivering tokens. At this point, her popularity declined until she also delivered tokens. The token economy manipulation appeared to have a specific, desirable effect on the targeted behavior (i.e., work rate) and had minimal negative or positive "side effects" on teacher popularity.

Attitude↗
PubMed2000

Polyunsaturated fatty acid (fish or evening primrose oil) for schizophrenia.

BACKGROUND: Limited evidence gives support to an hypothesis suggesting that the symptoms of schizophrenia may result from altered neuronal membrane structure and metabolism. The latter are dependent on blood plasma levels of certain essential fatty acids (EFAs) and their metabolites. Several studies have shown those with schizophrenia often have low levels of the particular EFAs necessary for normal nerve cell membrane metabolism. OBJECTIVES: To review the effects of supplementing standard antipsychotic treatment with polyunsaturated fatty acids, whether essential (EFAs) or non-essential, for those with schizophrenia and, in recent updates to also evaluate the effects of EFA's as a sole antipsychotic treatment. To evaluate the relative efficacy of different types of fatty acid supplementation. SEARCH STRATEGY: Relevant randomised trials were identified by searching the following electronic databases: Biological Abstracts (1985-1998), CINAHL (1982-1998), Cochrane Library (Issue 4, 1999), Cochrane Schizophrenia Group's Register (February 2000), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). In addition, reviewers searched references of included and excluded studies and contacted authors to identify further studies. SELECTION CRITERIA: All randomised clinical trials of polyunsaturated fatty acid supplementation to standard treatment or as primary intervention for schizophrenia (however defined) versus standard care. DATA COLLECTION AND ANALYSIS: Reviewers evaluated data independently and analysed on an intention-to-treat basis. They assumed that people who left the study early or were lost to follow-up had no improvement. Where possible and appropriate relative risk (RR) and their 95% confidence intervals (CI) were calculated. The number needed to treat (NNT) was estimated. For continuous data weighted mean differences (WMD) and their 95% confidence intervals were calculated. Data were inspected for heterogeneity and publication biases. MAIN RESULTS: Four relatively small trials (total n=204) showed low levels of loss to follow up and adverse effects for those taking essential fatty acids. Early results from a few trials suggest a positive effect of eicosapentaenoic acid (EPA) over placebo for scale-derived mental state outcomes. The data, however, is limited making these results difficult to analyse and interpret with confidence. A single small study (n=30) investigated the value of using EPA as sole treatment for people hospitalised for relapse. Results suggest that EPA may help one third of people avoid instigation of standard antipsychotic drugs for 12 weeks (RR 0.6, CI 0.4-0.91). There were no clear effects of primrose oil (omega-6) EFA supplementation. REVIEWER'S CONCLUSIONS: All data are preliminary, but results look encouraging for fish oil. EPA does not seem harmful, may be acceptable to people with schizophrenia and have moderately positive effect. A further trial is soon to be reported from the USA and more are underway or planned in the South Africa and Norway. Considering that EPA may be an acceptable intervention, large, long simple studies reporting clincially meaningful data should be anticipated.

Antipsychotic Agents↗
PubMed2002

A brief intervention for hazardous drinkers in a needle exchange program.

Active injection drug users (IDUs) who are also hazardous alcohol users are at particularly high risk for HIV transmission due to sharing of injection equipment. We recruited AUDIT-positive injectors from the Providence, RI needle exchange program for a randomized clinical trial testing the effect of a brief motivational intervention (MI) on frequency of injection-related HIV risk behavior (IRRB). HIV drug risk behavior was measured as the number of days on which subjects reported sharing works using the 30-day Timeline Followback Method. Overall, 109 subjects reported a mean reduction of IRRB days of 9.1 days from baseline to 6-month follow-up (p <.001). When compared to controls, there was a trend in reduction of IRRB days to zero at follow-up for MI subject (OR = 2.1; 95% CI = 0.9-4.5), and strongly significant reductions in IRRB days across a range of alternative improvement thresholds. Results from this study demonstrate that MI reduces drug-related HIV risk behaviors among active IDUs. As a brief intervention, MI may be a useful adjunct to existing services intended to reduce harm.

Adult↗
PubMed2006

Antioxidant status of interval-trained athletes in various sports.

Muscular exercise results in an increased production of free radicals and other forms of reactive oxygen species (ROS). Further, developing evidence implicates cytotoxins as an underlying etiology of exercise-induced stimuli in muscle redox status, which could result in muscle fatigue and/or injury. Two major classes of endogenous protective mechanisms (enzymatic and nonenzymatic antioxidants) work together to reduce the harmful effects of oxidants in the cell. This study examined the effects of acute physical exercise on the enzymatic antioxidant systems of different athletes and comparison was made to the mechanism of action of three main antioxidant enzymes in the blood. Handball players (n = 6), water-polo players (n = 20), hockey players (n = 22), basketball players (n = 24), and a sedentary control group (n = 10 female and n = 9 male) served as the subjects of this study. The athletes were divided into two groups according to the observed changes of activity of superoxide dismutase enzyme. The antioxidant enzyme systems were characterized by catalase (CAT), glutathione-peroxidase (GPX), and superoxide-dismutase (SOD) and measured by spectrophotometry. An important finding in the present investigation is that when the activities of SOD increased, the activities of GPX and CAT increased also and this finding related to the physical status of interval-trained athletes. Positive correlation between SOD and GPX activities was observed (r = 0.38 females, r = 0.56 males; p < 0.05). We have observed that the changes in the primary antioxidant enzyme systems of athletes are sport specific, and different from control subjects. Presumably, with interval-trained athletes, hydrogen-peroxide is significantly eliminated by glutathione-peroxidase. From these results it can be concluded that the blood redox status should be taken into consideration when establishing a fitness level for individual athletes.

Adolescent↗
PubMed2000

Relationships between work environments, psychological environments and psychological well-being.

Work environments appear to have both positive and negative impacts on the psychological well-being of workers. This paper reviews a number of models and theories that have addressed this issue. First, those aspects of the psychological work environment, which are thought to be most relevant to well-being, are described. Second, a number of models and theories are considered. How then is it possible to best understand how the work environment creates a psychological environment, which in turn may affect psychological well-being? While some of the available approaches are general and offer descriptive frameworks, others do attempt to explain the relationships between a more narrow set of work characteristics and well-being. Further, recent approaches focus on explaining emotional reactions at work and the role of the psychological contract. A sound understanding of work and well-being is still some way away. However, focusing on more specific kinds of well-being, taking account of other contextual influences, and looking at both the salubrious and harmful effects of the work environment are likely to bring about greater understanding.

Adaptation, Psychological↗
PubMed2002

Helpful or harmful? The impact of strategic change on the performance of U.S. urban hospitals.

OBJECTIVE: To contribute to the debate as to whether strategic change helps or harms organizations by empirically examining how strategic change influences performance change in urban hospitals. DATA SOURCES: AHA Annual Survey (1994 and 1996), Health Care Financing Administration's Medicare Cost Reports (1994 and 1996) and Medicare HMO Files (1994), U.S. Bureau of the Census' County Business Patterns Files (1994), and Area Resources File (1994). STUDY DESIGN: This work employed a longitudinal approach using a panel design to study the effect of environmental and organizational characteristics on urban hospital strategic behavior and performance. A path analytic model was used to examine the simultaneous effects of environmental and organizational characteristics (1994) on strategic behavior (change in strategies to enhance HMO business and change in strategies to control costs 1994-96), as well as the effects of all of these variables on change in urban hospital performance (change in market share, change in operational efficiency, change in financial performance 1994-96). PRINCIPAL FINDINGS: (1) Environmental context exerts a greater influence on urban hospitals' HMO business enhancement strategies, whereas organizational characteristics have more influence on cost-control strategies. (2) Between the two strategies, HMO business enhancement and cost control, strategic change to enhance business with HMOs is much more complex. (3) Strategic change observed across the 1994 to 1996 time period can be either helpful or harmful to urban hospitals. A strategic change that contributes positively to one type of performance can negatively impact the other. CONCLUSIONS: Although differences of opinion persist in the strategic change debate, results of this study indicate that strategic change can be helpful or harmful to urban hospitals, and its consequences are far more complex than previously thought. Strategic rationality has its own limitations and cannot always be relied on to yield expected results. Hospital strategic changes require coordination to achieve greater performance results.

Data Collection↗
PubMed2004

The influence of environmental factors and education on tobacco smoking among students of the Faculty of Nursing, Medical University of Lublin.

Tobacco smoking among medical personnel is a problem concerning not only our country. Nurses and midwives in their work have a close contact with patients allowing influence on their health behaviours. Positive own example is indispensable in this field. Formation of proper attitudes and healthy behaviours should be one of the main goals of academic education of nurses and midwives. The aim of the study was an attempt at analysing the problem of tobacco smoking among the students of the Faculty of Nursing, Medical University of Lublin. The material consisted of 152 anonymous questionnaires filled in by the students in the academic year 2001/2002. There was applied the method of standardized interview using an interview questionnaire. The material was analysed by means of descriptive statistics methods. Women were more prevalent among the respondents (143 persons out of 152), the mean age equalled 29.4 years. The majority were students of nursing (109 persons) and 43 represented midwifery. Twenty-seven percent of all students declared tobacco smoking, 13% quitted the habit and 60% never smoked. The studies proved that medical education and knowledge of harmfulness of tobacco smoking are the main reasons of non-smoking habits of the analysed group of students. The decision about taking up smoking is mostly influenced by smoking peers. This testifies to the need of further educational actions during nursing studies that would promote proper health behaviours in this field.

Adult↗
PubMed2003

In praise of boundaries. A conversation with Miss Manners. Interview by Diane L. Coutu.

The past three decades have been a time of increasing informality in the American workplace. It's easy to characterize this growing comfort with the casual as a positive step for workplace culture, an outgrowth of the American democratic belief in workers' equality. Informal environments are said to be more trusting and open, and workers who are free to express their personalities are more comfortable and thus more creative--right? According to etiquette guru Judith Martin--known far and wide as Miss Manners--informality in the workplace may do more harm than good. Without some formality in social intercourse, Miss Manners argues, human interactions end up being governed by laws, which are too heavy-handed to serve as a guide through the nuances of personal--or professional--behavior. Since our earliest beginnings, we have developed formal rules to accompany shared human experiences, such as eating and mourning. Yet, says Miss Manners, something in us rebels against form and etiquette, and every so often, an anti-manners movement takes hold, and people come to believe that following etiquette is unnatural. One recent such movement has led to the belief that a distinction between our work life and our professional life is unnecessary. If we hope to reassure our customers that we are indeed professional, however, we need to be aware of the boundaries of professional behavior. On the whole, Miss Manners argues, informality in the workplace leads to a host of problems, from making employees feel pressured to "socialize" with coworkers during weekends and evenings to sexual harassment. Despite the shortcomings of informality in the American workplace, though, Miss Manners believes that we have the best code of manners the world has ever seen-in theory. In practice, American etiquette is undoubtedly still a work in progress.

Efficiency, Organizational↗
PubMed2005

[First experience with a critical incident reporting system in surgery].

Systems that record critical incidents were initially developed for aeronautics and are being increasingly applied in medicine. The objective is to detect problems inherent to systems and system errors before they lead to complications or do harm to patients. We report our preliminary experience with a critical incident reporting system (CIRS). Since February 1 2001, all employees of our surgical department have been able to report incidents, anonymously or candidly, to a central board using a standardized documentation form. The results are presented at monthly internal quality meetings, where two to three crucial incidences are thoroughly discussed. New information is communicated and put into practice as quickly as possible. A total of 424 incidents were reported from February 1, 2001 to December 31, 2003. Reversible damages, some of which resulted in prolonged hospitalization, were consequential to 22% of the cases. Thirteen percent were classified as "near miss" (almost incidents), whereas 65% had no consequences for patients. As expected, doctors and nurses were most frequently involved, as 36% of the reported incidents occurred in connection with the prescription and administration of medication. In particular, the near miss category revealed system errors which in 85% of cases had immediate consequences for therapeutic procedures. Based on our initial experiences, working with CIRS may be evaluated as positive. The open discussion of incidents and errors also revealed minor but often significant system errors, which resulted in alteration of our internal proceedings and thus improved the quality and safety of treatment.

Data Collection↗
PubMed2006

Clinical practice with anti-dementia drugs: a consensus statement from British Association for Psychopharmacology.

The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review the evidence on the drug treatment for dementia. The level of evidence (types) was rated using a standard system: Types 1a and 1b (evidence from meta-analysis of randomised controlled trials or at least one controlled trial respectively); types 2a and 2b (one well-designed study or one other type of quasi experimental study respectively); type 3 (non-experimental descriptive studies); and type 4 (expert opinion). There is type 1a evidence for cholinesterase inhibitors (donepezil, rivastigmine and galantamine) for mild to moderate Alzheimer's disease; memantine for moderate to severe Alzheimer's disease; and for the use of bright light therapy and aromatherapy. There is type 1a evidence of no effect of anti inflammatory drugs or statins. There is conflicting evidence regarding oestrogens, with type 2a evidence of a protective effect of oestrogens but 1b evidence of a harmful effect. Type 1a evidence for any effect of B12 and folate will be forthcoming when current trials report. There is type 1b evidence for gingko biloba in producing a modest benefit of cognitive function; cholinesterase inhibitors for the treatment of people with Lewy body disease (particularly neuropsychiatric symptoms); cholinesterase inhibitors and memantine in treatment cognitive impairment associated with vascular dementia; and the effect of metal collating agents (although these should not be prescribed until more data on safety and efficacy are available). There is type 1b evidence to show that neither cholinesterase inhibitors nor vitamin E reduce the risk of developing Alzheimer's disease in people with mild cognitive impairment; and there is no evidence that there is any intervention that can prevent the onset of dementia. There is type 1b evidence for the beneficial effects of adding memantine to cholinesterase inhibitors, and type 2b evidence of positive switching outcomes from one cholinesterase inhibitor to another. There is type 2a evidence for a positive effect of reminiscence therapy, and type 2a evidence that cognitive training does not work. There is type 3 evidence to support the use of psychological interventions in dementia. There is type 2 evidence that a clinical diagnosis of dementia can be made accurately and that brain imaging increases that accuracy. Although the consensus statement dealt largely with medication, the role of dementia care in secondary services (geriatric medicine and old age psychiatry) and primary care, along with health economics, was discussed. There is ample evidence that there are effective treatments for people with dementia, and Alzheimer's disease in particular. Patients, their carers, and clinicians deserve to be optimistic in a field which often attracts therapeutic nihilism.

Aged↗
PubMed1998

The use of nonopioid drugs in management of chronic orofacial pain.

Although controversial, opioid analgesics have been prescribed for patients with chronic facial pain. Based primarily on survey data and a few well-controlled clinical trials, long-term opioid treatment provides adequate pain reduction in 41% to 100% of patients with chronic nonmalignant pain. However, only 25% of chronic facial pain patients reported adequate pain relief with chronic opioid treatment. Work, home, and school function are generally reestablished or maintained during chronic opioid treatment, but 25% to 38% of patients remain dysfunctional, and one study indicated that 20% of patients became dysfunctional during treatment. Chronic opioid treatment is associated with many transient side effects; constipation, dizziness, nausea, vomiting, itching, and fatigue have been reported in 5% to 42% of patients taking opioids over 1 year. Although survey studies suggest that the risks of addiction are low in typical patients, drug abuse rates up to 17.3% and prescription abuse rates up to 27.6% were reported within groups of chronic opioid users. Chronic opioid use induces analgesic tolerance and physical dependence, which may result in a serious abstinence syndrome in users and children born to users. Chronic opioid use also may induce harmful immune system changes, diminish cognitive and motor function, and produce nociceptive hyperexcitability. This article shows that the use of long-term opioids for chronic facial pain is not justified based on the available data. Despite these perceived problems, there is anecdotal evidence that chronic facial pain patients will respond positively to opioid analgesics. In our experience, the pain assessment scale and a modification of the World Health Organization's three-step analgesic ladder, which prescribes nonopioid analgesics, can be the starting point for the successful management of chronic facial pain.

Analgesics↗
PubMed2005

[Primary prevention program of the Hungarian Spine Society--part I. Scientific background of the posture correction exercise scheme].

The primary prevention program of the Hungarian Spine Society aims to increase awareness of the need to develop and automatically maintain a biomechanically correct posture for all school children. The biomechanically correct posture is a dynamic balance based on a correct middle position of the pelvis and on muscle balance. In this position three important anatomical points--the left and right anterior superior iliac spines and the upper medial point of the pubic bone--form one frontal plane. From side-view the imaginary weight median of the body crosses the 2nd to 5th lumbar and the 2nd to 5th cervical vertebral bodies. When the muscles involved in posture are in balance, their strength and flexibility are just appropriate for the almost continuous work required against gravity. In case of static and/or dynamic under- or overload tonic muscles become shortened, and phasic muscles become stretched, and are no longer able to work optimally. Since many muscles and muscle parts that are involved in normal posture maintenance are not satisfactorily challenged in regular physical exercises and sport activities, the preventive exercise scheme of the Hungarian Spine Society aimed to involve these rarely used muscles in special strengthening and stretching exercises. The scheme is based on 12 test exercises that assess the strength and flexibility of postural muscles. A person who is able to do all test exercises correctly has no problem with his or her muscle balance. In order to counteract the harm caused by sedentary lifestyle already in childhood, regular use of this posture correction scheme in physical education starting from preschool throughout the school-years is recommended for all children.

Biomechanical Phenomena↗
PubMed2004

Criticizing and reassuring oneself: An exploration of forms, styles and reasons in female students.

OBJECTIVES: Self-critical people, compared with those who self-reassure, are at increased risk of psychopathology. However, there has been little work on the different forms and functions of these self-experiences. This study developed two self-report scales to measure forms and functions of self-criticism and self-reassurance and explore their relationship to depression. METHODS: A self-report scale measuring forms of self-criticism and self-reassuring, and a scale measuring possible functions of self-criticism, together with a measure of depression and another self-criticism scale (LOSC), were given to 246 female students. RESULTS: Self-criticizing vs. self-reassuring separated into two components. Forms of self-criticizing separated into two components related to: being self-critical, dwelling on mistakes and sense of inadequacy; and a second component of wanting to hurt the self and feeling self-disgust/hate. The reasons/functions for self-criticism separated into two components. One was related to desires to try to self-improve (called self-improving/correction), and the other to take revenge on, harm or hurt the self for failures (called self-harming/persecuting). Mediation analysis suggested that wanting to harm the self may be particularly pathogenic and is positively mediated by the effects of hating the self and negatively mediated by being able to self-reassure and focus on one's positives. CONCLUSIONS: Self-criticism is not a single process but has different forms, functions, and underpinning emotions. This indicates a need for more detailed research into the variations of self-criticism and the mechanisms for developing self-reassurance.

Adult↗
PubMed2002

Drugs in the parallel market for the treatment of urethral discharge in Dakar: epidemiologic investigation and physicochemical tests.

OBJECTIVE: Sexually transmitted diseases (STDs) constitute a major public health concern in developing countries. Their interest lies mainly in their diagnosis and their early treatment. Owing to lack of health education and poor living conditions inherent in underdevelopment, self-medication is common practice in these Third World countries. Therefore, the illegal sale of drugs is an important phenomenon in Africa and Asia. METHODS: An investigation, with a view to evaluating the importance of drug sales in the parallel market for the treatment of urethral discharge in Dakar, was carried out in 50 different locations in the working-class districts of the capital from 13 February to 6 March 1997. These drugs, obtained from vendors in the illegal market, were tested and analyzed using the standard physicochemical methods. RESULTS: The most frequently proposed drugs to treat male urethritis are: ampicillin 250-mg capsules (44%); oxytetracyline 250-mg capsules (24%); and cotrimoxazole 450-mg tablets (12%). In most cases (88%), these drugs were sold unpackaged; 12% were sold in blisters. Furthermore, in 90% of cases, the expiry date was not indicated. The dosage and duration of treatment were correct in only 6% of cases. The physicochemical analysis was based on the external appearance, the identification, and the dosage of the active principle. Of these drugs offered by street vendors, 53.1% had an unusual appearance; they were mainly ampicillin 250 mg (21 of 22 samples) and oxytetracycline 250 mg (6 of 12 samples). Furthermore, all active principles were identified as positive, with the exception of ampicillin 250 mg, for which only one sample of the 22 was positive; the others appeared to be flour, with no trace of the active principle. CONCLUSION: Given the extent of these illegal sales of drug and their harmful consequences for the health of the population, adequate measures should be taken to eradicate this blight. For this mission to succeed, public authorities, health professionals and populations should combine their efforts.

Ampicillin↗
PubMed1990

Total parenteral nutrition 1990. A review of its current status in hospitalised patients, and the need for patient-specific feeding.

The decision to initiate total parenteral nutrition (TPN) in hospitalised patients should be based on the presence of clinically significant starvation and dysfunction of the gastrointestinal tract. It must also take into account the clinical status of the patient, considering major treatment strategies and the need for prolonged hospitalisation, the benefits of feeding and the attendant risks of central venous alimentation. Recent evidence in surgical patients in intensive care provides the impetus for early parenteral feeding; withholding TPN and inducing a cumulative caloric deficit of greater than or equal to 10,000 calories has been associated with a survival disadvantage compared to those patients with a positive caloric balance. Moreover, the incidence of serious organ failure was consistently higher in the group with cumulative caloric deficits. Additional evidence favouring the provision of TPN exists, but the axiom 'if the gut works, use it' still prevails. Exceptions to this precept do exist, however, particularly in critically ill patients. The metabolic derangements encountered in these patients could be so severe that it may be impossible to correct the electrolyte and acid-base abnormalities via the enteral route. For example, such patients may have large potassium requirements and/or severe alkalaemia necessitating systemic acidification with hydrochloric acid, precluding enteral delivery due to gastrointestinal intolerance. In this setting, combined enteral feeding with 10 to 20 ml/h to maintain gut integrity (via a post-pyloric feeding tube) and TPN during the acute phases of illness is an exciting possibility. Once the decision to feed is made, the amount of nutrition prescribed may assume equal importance with respect to patient outcome. The frequent use of the Harris-Benedict equation, plus a multiplying factor for stress, may overestimate caloric requirements; this is particularly true during critical illness. The dangers of overfeeding may be just as harmful as not feeding at all. The use of indirect calorimetry provides the most accurate measurement of resting energy expenditure. However, in the absence of indirect calorimetry, modified equations to estimate caloric needs are available. Caution must be observed as caloric intakes exceeding the range of 25 to 35 kcal/kg may be dangerous, particularly in the severely ill patient with preexisting organ failure. The amount of protein and the 'calorie-mix' necessary for optimal nutritional support is open to debate. Recent evidence has demonstrated no additional benefit to nitrogen balance in severely septic patients when protein was given at a level exceeding 1.5 g/kg/day.(ABSTRACT TRUNCATED AT 400 WORDS)

Critical Care↗