Disminución de la debilidad muscular adquirida en una unidad de cuidados intensivos con la implementación de un protocolo multicomponente: ensayo clínico cuasiexperimental

Introducción. La debilidad adquirida en las unidades de cuidados intensivos es una complicación frecuente de los pacientes con enfermedades críticas, que puede tener un impacto negativo en su pronóstico a corto y a largo plazo. Objetivos. Evaluar si la utilización de un protocolo multicomponente, que incluye movilidad activa temprana, manejo efectivo del dolor, reducción de la sedación, medidas no farmacológicas para prevenir el delirium, estimulación cognitiva y apoyo familiar, puede disminuir la incidencia de debilidad adquirida en las unidades de cuidados intensivos al momento del egreso del paciente. Materiales y métodos. Se trata de un ensayo clínico, no aleatorizado, en dos unidades de cuidados intensivos mixtas de un hospital de tercer nivel. Los participantes fueron pacientes mayores de 14 años con ventilación mecánica invasiva por más de 48 horas. Se aplicó como intervención un protocolo multicomponente y como control se utilizó el cuidado usual o estándar. Resultados. Ingresaron 188 pacientes al estudio, 82 al grupo de intervención y 106 al grupo control. La tasa de debilidad adquirida en las unidades de cuidados intensivos al egreso de la unidad fue significativamente menor en el grupo de intervención (41,3 % versus 78,9 %, p<0,00001). La mediana del puntaje de movilidad al momento del alta de la unidad de cuidados intensivos fue mayor en el grupo de intervención (3,5 versus 2, p<0,0138). No se encontraron diferencias estadísticamente significativas en las medianas de días libres de respiración mecánica asistida, ni de unidad de cuidados intensivos al día 28, tampoco en la tasa de mortalidad general al egreso del hospital (18 versus 15 días, p<0,49; 18,2 % versus 27,3 %, p<0,167). Conclusiones. Un protocolo multicomponente que incluía movilidad activa temprana tuvo un impacto significativo en la reducción de la debilidad adquirida en las unidades de cuidados intensivos al egreso en comparación con el cuidado estándar.

Introduction. Intensive care unit-acquired weakness is a frequent complication that affects the prognosis of critical illness during hospital stay and after hospital discharge. Objectives. To determine if a multicomponent protocol of early active mobility involving adequate pain control, non-sedation, non-pharmacologic delirium prevention, cognitive stimulation, and family support, reduces intensive care unit-acquired weakness at the moment of discharge. Materials and methods. We carried out a non-randomized clinical trial in two mixed intensive care units in a high-complexity hospital, including patients over 14 years old with invasive mechanical ventilation for more than 48 hours. We compared the intervention -the multicomponent protocol- during intensive care hospitalization versus the standard care. Results. We analyzed 82 patients in the intervention group and 106 in the control group. Muscle weakness acquired in the intensive care unit at the moment of discharge was less frequent in the intervention group (41.3% versus 78.9%, p<0.00001). The mobility score at intensive unit care discharge was better in the intervention group (median = 3.5 versus 2, p < 0.0138). There were no statistically significant differences in the invasive mechanical ventilation-free days at day 28 (18 versus 15 days, p<0.49), and neither in the mortality (18.2 versus 27.3%, p<0.167). Conclusion. A multi-component protocol of early active mobility significantly reduces intensive care unit-acquired muscle weakness at the moment of discharge.

Fishes from the Colombian Amazonia region: species composition from the river systems within the rainforest biome / Peces de la región de la Amazonía Colombiana: composición de especies de los sistemas fluviales del bioma de selva húmeda

Abstract The Colombian Amazon region is part of the Neotropical rainforest (humid forest biome) covering an area of 483,163 km2 and includes tributaries of both the Amazon and Orinoco River basins. The aquatic ecosystems found there include: rivers and alluvial plains originating in Andean headwaters, on eroded soils of tropical forests in the lowlands, and Guiana Shield formations, comprising a dense fluvial drainage network in the lowlands, with Paleogene/Neogene geological formations (terra firme streams in higher places that don't usually flood) and Paleozoic (shield streams); and Andean and Guiana Shield streams above 200-250 m a.s.l. We present here an exhaustive compilation of published information, supported by fish collections, consisting of a list of 1104 species distributed in 375 genera, 53 families, and 16 orders. We include occurrence data of these species in each sub-basin. The presence/absence species matrix was analyzed using a dendrogram and non-metric multidimensional scaling (NMDS) analysis to identify patterns of similarity between basins and sub-basins. We evaluated species composition between basins and among the different geological origins using PERMANOVA. The dendrogram shows co-occurrences of 404 species in the two basins. It also shows two clear groupings of the sub-basins of the Amazon (except Guainía-Negro drainages) and those of the Orinoco. Within the Amazon Basin, there are two nodes according to the geological origin: systems of Andean origin and those of the lowlands. The dendrogram results are consistent with the NMDS analysis, which shows a clear grouping according to the connectivity of the basins; the Guainía-Negro is included in the Amazon basin. Species distribution patterns were supported by the PERMANOVA, and differed significantly between basins (F = 4.3, R = 0.26, P = 0.003) and geological origin (F = 3.6, R = 0.23, P = 0.003). The number of species in this study represents almost a fifth of the ichthyofauna of the Neotropics and about a third of that of the Amazon River basin; clearly supporting Colombia's status among the countries with the greatest diversity of freshwater fish species of the planet. We include here a significant number of new records (75 spp), provide a first approximation of the distribution patterns, and a framework for future biogeographical studies.

Resumo La región de la Amazonía colombiana hace parte del bosque húmero neotropical (bioma de selva húmeda) abarcando un área de 483.163 km2 e incluye afluentes de las cuencas del Amazonas y Orinoco. Los ecosistemas acuáticos encontrados allí incluyen: ríos y llanuras aluviales, originándose en cabeceras andinas, en suelos erosionados de bosques tropicales en tierras bajas y en formaciones de escudos; conformando una densa red fluvial en tierras bajas con formaciones geológicas paleógenas-neógenas (arroyos de terra firme en sitios elevados que usualmente no se inundan) y paleozoicas (arroyos de escudo); y arroyos andinos y del escudo Guayanés por encima de 200-250 m s.n.m. Presentamos aquí una recopilación exhaustiva de información publicada, sustentada por colecciones ictiológicas, consistiendo en una lista de 1104 especies distribuidas en 375 géneros, 53 familias y 16 órdenes. Incluimos datos de estas especies en cada subcuenca. La matriz de presencia/ausencia de especies fue analizada usando un dendrograma y un análisis de escalamiento multidimensional no métrico (NMDS) para identificar patrones de similitud entre cuencas y subcuencas. Se evaluó la composición de especies entre cuencas y entre los diferentes orígenes geológicos usando PERMANOVA. El dendrograma refleja coocurrencia de 404 especies en las dos cuencas. También muestra dos agrupaciones claras de las subcuencas del Amazonas (excepto Guainía-Negro) y las del Orinoco. Dentro de la cuenca amazónica existen dos nodos según el origen geológico: los sistemas de origen andino y los de tierras bajas. Los resultados del dendrograma son consistentes con el análisis NMDS, el cual muestra una clara agrupación según la conectividad de las cuencas; el Guainía-Negro está incluido en la cuenca del Amazonas. Los patrones de distribución de especies fueron respaldados por el PERMANOVA y difirieron significativamente entre cuencas (F = 4.3, R = 0.26, P = 0.003) y origen geológico (F = 3.6, R = 0.23, P = 0.003). El número de especies en este estudio representa casi la quinta parte de la ictiofauna del Neotrópico y alrededor de un tercio de la de la cuenca del río Amazonas; soportando el estatus de Colombia entre los países con mayor diversidad de especies de peces de agua dulce del planeta. Incluimos aquí un número importante de nuevos registros (75 spp), brindamos una aproximación de los patrones de distribución y un marco para futuros estudios biogeográficos.

WEBINAR ORAS-CONHU: SARS CoV2 / COVID-19 NIÑOS, NIÑAS Y ADOLESCENTES AVANCES EN VACUNACION / ORAS-CONHU WEBINAR: SARS CoV2 / COVID-19 CHILDREN AND ADOLESCENTS ADVANCES IN VACCINATION

El 10 de febrero de 2021 se realizó el webinar 105° Oportunidad y Calidad de la vacuna contra el coronavirus para niños y niñas en la Región Andina. Esta presentación realizada por José Alejandro Mojica, Infectólogo Pediatra de la Subdirección de Enfermedades Transmisibles del Ministerio de Salud y Protección Social Colombia, contiene: epidemiología SARS COV 2/COVID 19, clínica y manejo niños, niñas y adolescentes, vacunas en pediatría y retos.

Spatial and temporal distribution of Gymnorhamphichthys rondoni (Gymnotiformes: Rhamphichthyidae) in a long-term study of an Amazonian terra firme stream, Leticia - Colombia

Weakly electric fishes continually emit electric organ discharges (EOD) as a means of communication and localization of objects in their surroundings. Depending on water conductivity, the amplitude of the electric field generated is known to increase with decreases in electrical conductivity of the water. In Amazonian terra firme streams, water conductivity is extremely low and fluctuates constantly due to local and regional rains. In this context, the space between freely moving weakly electric fishes may be expected to decrease, on average, with an increase in water conductivity. To test this hypothesis, we recorded the positions at rest of the sand-dwelling fish Gymnorhamphichthys rondoni in a terra firme stream for several days in alternating months, over two years. Based on daily nearest neighbor distances among individual fish in a grid, we found a uniform temporal distribution pattern (which was not affected by water conductivity) indicative of site fidelity. Here we highlight the role of other factors that could influence resting site fidelity.(AU)

Los peces eléctricos emiten continuamente descargas con su órgano eléctrico (DOE) para comunicarse y localizar objetos a su alrededor. Dependiendo de la conductividad del agua, la amplitud del campo eléctrico generado aumenta con una disminución en la conductividad eléctrica del agua. En los arroyos de terra firme amazónicos, la conductividad eléctrica del agua es extremadamente baja y fluctua constantemente dependiendo de las lluvias locales y regionales. Teniendo esto en cuenta, esperamos que el espacio entre peces eléctricos débiles con libertad de movimiento disminuya, en promedio, de acuerdo al incremento en la conductividad del agua. Para evaluar esta hipótesis, registramos bajo condiciones naturales por varios dias en meses alternos y durante dos años las posiciones en reposo del pez Gymnorhamphichthys rondoni en un arroyo de terra firme. Con los valores de registro diario de la distancia al vecino mas cercano en peces individuales dentro de una grilla, encontramos un patrón de distribución temporal uniforme (que no fue afectado por la conductividad del agua) e indicativo de una fidelidad por los sitios de reposo. Entonces, nosotros resaltamos aquí el posible papel que otros factores pueden estar jugando para entender la fidelidad por sus sitios de reposo.(AU)

Comparison of abbreviation usage practices in two Philippine tertiary hospitals and perceived effects on medical training

OBJECTIVES:To (1) compare abbreviation usage practices in the Doctors' Orders and History Sheet in two tertiary hospitals in Cebu City, namely, Cebu Velez General Hospital (CVGH) and Vicente Sotto Memorial Medical Center (VSMMC); (2) determine why medical students and physicians use abbreviations and (3) determine the perceived effects on medical student training. METHODS:This is a descriptive cross-sectional study utilizing medical chart reviews as well as group and key informant interviews. Stratified Random Sampling with Proportionate Allocation was used to select 100 charts each from CVGH and VSMMC. Purposive sampling was done for key informants. RESULTS: All patients' clinical history, physical examination and doctors' orders in all departments of both hospitals contained abbreviations. First initialization was the most common form, e.g. BP (blood pressure). Non-universally-accepted abbreviations were common, e.g. HFD (heredofamilial disease). Potentially dangerous abbreviations were noted, e.g. d/c, D/C. Abbreviations were used to maintain patient-doctor confidentiality, save space and time, and for convenience. Perceived effects on medical training included speeding up of task performance. CONCLUSIONS: Use of abbreviations in medical charts among medical students and physicians in both private and public tertiary hospitals in the Philippines is a prevalent practice. While such has its perceived benefits, it also poses potential danger to patients because not all abbreviations are understood and used the same way. Medical schools and their training hospitals must initiate moves to standardize the use of abbreviations in medical education and promote awareness of their potential dangers. The authors suggest that potential dangers/benefits of abbreviations be formally introduced in medical school as a separate topic.

The gait, arms, legs and spine (GALS) locomotor screen teaching-learning package: Has it achieved its intended learning outcome?

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions. OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics. METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation. RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique. CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.

The gait, arms, legs and spine (GALS) locomotor screen teaching-learning package: Has it achieved its intended learning outcome?

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions. OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics. METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation. RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique. CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.

Functional outcome of stroke in the young patients undergoing rehabilitation at the Philippine General Hospital

OBJECTIVES: Because of the growing concern for stroke in the young, this study was done to determine functional outcome among patients seen at the out-patient clinic of the Department of Rehabilitation Medicine, Philippine General Hospital. METHODS: Twenty-two patients diagnosed to have stroke in the young, who were referred for comprehensive rehabilitation and satisfied the inclusion criteria participated in this prospective study. The patients were evaluated using the Institute of Rehabilitation and Restorative Care-Long Range Evaluation System. The scores were analyzed using paired t-test, repeated measures ANOVA and linear regression at 95% confidence level. RESULTS: Significant changes across time in all variables tested: communication, motor function of the affected extremity, the unaffected extremity, proficiency in self-cafe activities, family cluster, social cluster, resources, outlook in life and work status. Significant changes were also noted between the first and second, and between the second and third evaluation periods. Family cluster, resources and the motor functional outcome of the patients. CONCLUSION: The present study suggests that it is not the improvement in motor recovery alone but also increased psycho-social support that determine functional outcome for stroke in young patients.

Estimación de la fuerza de infección de Hepatitis A en Colombia, aplicando modelos catalíticos / Assessing the force of hepatitis A virus infection in Colombia by applying catalytic models

Objetivo Estimar la fuerza de infección de hepatitis A en la población de niños entre 1 a 15 años de edad que asistieron a seis centros de salud en Colombia entre el año 2007 y 2008, aplicando modelos catalíticos. Métodos En 2 152 pacientes de seis centros de salud en cinco ciudades de Colombia se estimó la seroprevalencia de anticuerpos contra el virus de la Hepatitis A (anti-VHA) por grupos de edad. Con base en esta estimación, se obtuvo la fuerza de infección y la edad promedio de infección para cada región ajustando modelos catalíticos. Resultados La fuerza de infección fue de 0,15 en el grupo de 1 a 4 años en Barranquilla. En el resto de ciudades la fuerza de infección tomó valores entre 0,02 para Bogotá en el grupo de 5 a 15 años, y 0,06 para Medellín en el grupo de 1 a 9 años. La edad promedio de infección en Bogotá, Bucaramanga, Cali y Medellín estuvo entre 10,7 y 12,0 años. Conclusión En Bogotá, Bucaramanga, Cali y Medellín se estimaron seroprevalencia de anti-VHA entre 26,3 % y 40,4 % en el grupo de 10 a 15 años, con una edad promedio de infección entre 10,7 y 12,0 años; comportamiento semejante a la de regiones en desarrollo con endemicidad intermedia.

Aims Estimating the force of hepatitis A virus (HAV) infection concerning a 1- to 15-year-old child population being attended at six healthcare centres in Colombia by applying catalytic models. Methods Anti-HAV seroprevalence was estimated in 2,152 patients attending six health centres in 5 Colombian cities; based on such estimation, the force of infection and average age of infection were obtained for each region. Results The 1- to 4-year-old age group’s force of infection was 0.15 in Barranquilla; for the other cities the force of infection was 0.02 in Bogotá for the 5- to 15-year-old age group and 0.06 in Medellin for the 1- to 9-year-old age group. Average infection age in Bogotá, Bucaramanga, Cali and Medellin was 10.68 to 11.97 years-old. Conclusion There was high anti-HAV prevalence in the young-adult population, average infection age being 10.69 to 11.97 years-old, thereby presenting a similar pattern to that of developing regions having intermediate level of endemicity.

Evaluation of the Master of Science in Epidemiology (Clinical Epidemiology) curriculum

OBJECTIVES: To evaluate the relevance, usefulness, applicability, responsiveness, acceptability, efciency, overall impact and sustainability of the Master of Science in Epidemiology-Clinical Epidemiology (MSE-CE) curriculum. METHODS: The context, input, process and product evaluation (CIPP) design was used. Of 106 alumni and students, 100 were contacted and 80 participated in a survey. Key informant interviews, direct observation and focus group discussions with faculty members, present and past administrators, selected alumni and students, and review of data were done. The results were analyzed using descriptive statistics and content analysis. RESULTS: Context evaluation revealed that MSE-CE responded to the need to train physicians to use research evidence in clinical decision-making. Despite some reservations among other UP colleges, the program pushed through due to support from local and international sponsors. Alumni and students appreciated the effectiveness of their teachers and complementing instructional resources. The range of work by its graduates, the networks established, and the expansion of the Department of Clinical Epidemiology (DCE, the UP department ofering the MSE-CE program) prove that the MSE-CE is a sustainable post-graduate program. CONCLUSION: The MSE-CE institutionalized clinical epidemiology as a distinct discipline among medical colleges in the Philippines.

Balance de nitrógeno y fósforo de vacas lecheras en pastoreo con diferentes ofertas de kikuyo (Pennisetum clandestinum) suplementadas con ensilaje de avena (Avena sativa) / Saldo de nitrogênio e fósforo a partir de vacas leiteiras em pastagem com diferentes ofertas de capim Kikuyu (Pennisetum clandestinum) silagem suplementada com aveia (Avena sativa) / Nitrogen and phosphorus balance of cows offered different amounts of Kikuyu (Pennisetum clandestinum) and supplemented with oats (Avena sativa) silage

Nitrógeno (N) y fósforo (P) son elementos implicados en la contaminación ambiental. Con el objetivo de evaluar el balance de N y P se utilizaron 18 vacas bajo pastoreo en pasto kikuyo (Pennisetum clandestinum) en el Centro Agropecuario Marengo en Mosquera (Cundinamarca, Colombia). Los tratamientos consistieron en tres niveles (0, 0.7 y 1.4% del peso vivo) de oferta de ensilaje (MS) de avena (Avena sativa). Esta oferta diaria fue complementada con pasto kikuyo en pastoreo hasta alcanzar una oferta total del 4%. La relación kikuyo:ensilaje fue de 4:0, 3.3:0.7 y 2.6:1.4 para los tratamientos 1, 2 y 3, respectivamente. El ensilaje se suministró diariamente (AM y PM) en el potrero. Las vacas recibieron un alimento balanceado comercial a razón de 1kg por cada 4.2 kg de leche producida, y se mantuvo constante durante el periodo experimental que duró 14 días, con siete días de adaptación y siete de mediciones. La producción de leche (AM, PM) fue medida de manera individual; mientras que la producción de orina y heces fue medida los días 0, 7, y 14, para cuantificar N y P. El volumen de orina se estimó usando creatinina y el consumo usando cromo (cantidad de heces) y fibra en detergente acido indigerible (digestibilidad). El consumo de N (667.8 g/día) y la excreción en orina (240.6 g/d) fueron significativamente mayores (p<0.05) para el tratamiento 1 que para los tratamientos 2 (560.7 y 199.7 g/d) y 3 (594.8 y 200.8 g/d); sin embargo, no se encontraron diferencias estadísticas significativas (p>0.05) en la eficiencia de utilización de N (15.6; 16.6 y 15.1%, respectivamente). El consumo de P (98.2, 85.9, y 93.4 g/d), la excreción en orina (0.43, 0.39, y 0.48, g/d) y en heces (91.9, 100.7, y 108.6 g/d) no fueron estadísticamente diferentes entre tratamientos (p>0.05); sin embargo, el balance de P fue significativamente mayor (p<0.05) para el tratamiento 1 (5.9 g/d) que para los tratamientos 2 (-15.1g/d) y 3 (-15.6 g/d).

Nitrogen (N) and Phosphorus (P) have been implicated in environmental pollution. To evaluate N a P balance, eighteen lactating multiparous Holstein cows grazing kikuyu in the Livestock Center Marengo in Mosquera (Cundinamarca, Colombia). The treatments consisting three allowances of oat silage 0, 0.7 and 1.4 kg/100 kg of body weight. This daily allowance was completed with kikuyu on grazing to obtain a total dry matter allowance of 4kg/100 kg of body weight. The kikuyu and silage ratio was 4:0; 3.3:0.7 and 2.6:1.4 for treatments 1, 2 and 3, respectively. Cows received a commercial balanced feed 1kg for each 4.2kg of milk, and it was maintained during all the experimental period. This period lasted 14 days and consisted of 7 adaptation days and 7 experimental days. Individual milk production was measured (AM PM) and samples of urine and feces were taken on days 0, 7 and 14 to determine N and P. Urine volume was estimated using creatinine and dry matter intake using chromium (feces volume) and Indigestible Acid Detergent Fiber (Digestibility). N intake (667.8 g/d) and urine N excretion (240.6 g/d) was greater for cows on treatment 1 than for treatment 2 (560.7 and 199.7 g/d respectively) and for treatment 3 (594.8 and 200.8 g/d) respectively. However no differences were found on the efficiency of N utilization that was 15.6; 16.6 and 15.1 % for treatments 1, 2, and 3, respectively. Daily P intakes (98.2; 85.9 and 93.4 g/d), P excretion in urine (0.43; 0.42; and 0.35 g/d) and P excretion in feces (91.8; 100.7 and 108.6) were not different between treatments, however phosphorus balance was positive and greater for cows on treatment 1 (5.9 g/d) than cows in treatments 2 and 3 (-15.5, and -15.6 g/d, respectively).

Azoto (N) e fósforo (F) são elementos envolvidos na poluição ambiental. Com o objetivo de avaliar o balanço de N e P foram usadas 18 vacas em pastagem de capim kikuyu grass (Pennisetum clandestinum) no Centro Agropecuario Marengo em Mosquera (Cundinamarca, Colombia). Os tratamentos consistiram de três níveis (0, 0.7 e 1.4% do peso corporal) lance silagem (MS) de aveia (Avena sativa). Essa oferta por dia foi complementado com pastagem Kikuyu em um lance de chegar a 4% do total da ração. A relação Kikuyu erva:silagem foi de 4:0, 3.3:0.7 e 2.6:1.4 para os tratamentos 1, 2 e 3, respectivamente. A silagem foi fornecida diariamente (AM e PM), no paddock. As vacas foram agraciados com uma alimentação equilibrada a uma taxa de 1 kg para cada 4.2 kg de leite produzido, e permaneceu constante durante o período experimental, que durou 14 dias, com sete dias de adaptação e sete dias de medidas. A produção de leite (AM, PM) foi medido numa base individual; enquanto a produção de urina e fezes foi mensurado dias 0, 7, e 14, para quantificar N e P. O volume de urina é considerada utilização e consumo de creatina usando cromo (quantidade de fezes) e fibra em detergente ácido indigestível (digestibilidade). O consumo de N (667.8 g/dia) e excretada na urina (240.6 g/d) foram significativamente maiores (p<0.05) para o tratamento 1 em comparação com os tratamentos 2 (560.7 e 199.7 g/d) e 3 (594.8 e 200.8 g/d); No entanto, não houve diferenças estatisticamente significativas (p>0.05) na eficiência de utilização de N (15.6, 16.6 e 15.1%, respectivamente). O consumo de P (98.2, 85.9 e 93.4 g/d), excreção de urina (0.43, 0.39 e 0.48 g/d) e nas fezes (91.9, 100.7 e 108.6 g/d) não foram estatisticamente diferentes entre os tratamentos (p>0.05); No entanto, o balanço de P foi significativamente maior (p<0.05) para o tratamento 1 (5.9 g/d) do que para os tratamentos 2 (-15.1 g/d) e 3 (-15.6 g/d).