Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients.

BACKGROUND: Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN). METHODS: A multicenter (n = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly. RESULTS: From the entire population (n = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; n = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; p = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; p = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; p = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; p = 0.001) compared with the PN-EN subgroup. CONCLUSION: The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.

Wild fish and seafood species in the western Mediterranean Sea with low safe mercury concentrations.

A total of 1345 specimens belonging to 58 different species of wild fish and seafood from the western Mediterranean Sea were analyzed to assess total mercury levels and to estimate which species meet the EU recommendations for human consumption (0.5 µg g-1 ww) in all cases. All fish species were caught off the Mediterranean coasts and intended for human consumption. All specimens were collected from local markets located in Spain, Italy and France that sell fish caught by local fishermen (Eivissa, Menorca, Mallorca, Alacant, L'Ampolla, Ametlla de Mar, Marseille, Genoa, Civitavecchia, Alghero) at different time periods. Mercury concentrations were measured by thermal decomposition-gold amalgamator-atomic absorption spectrometry. Only thirteen species were found that did not exceed 0.5 µg g-1 ww in any specimen analyzed. These safe species were sardines (Sardina pilchardus), anchovies (Engraulis encrasicolus), blue whiting (Micromesistius poutassou), picarel (Spicara smaris), blackspot seabream (Pagellus bogaraveo), gilthead seabream (Sparus aurata), pearly razorfish (Xyrichtys novacula), surmullet (Mullus surmuletus), painted comber (Serranus scriba), brown meagre (Sciaena umbra), salema (Sarpa salpa), common dolphinfish (Coryphaena hippurus) and squid (Loligo vulgaris). These species occupy different trophic levels, have different lengths and average weights, but show a low mercury concentration than others living in the same environments. Potential human consumption of these species as sole source of fish would imply estimated weekly intakes representing between 49% and 70% of the recommended provisional tolerable weekly intake of methylmercury in the worst case. Health authorities should pay specific attention to species that do not meet EU thresholds and make appropriate precautionary health recommendations, especially for pregnant women and children.

The Effect of Enteral Immunonutrition in the Intensive Care Unit: Does It Impact on Outcomes?

Background: The present research aimed to evaluate the effect on outcomes of immunonutrition (IMN) enteral formulas during the intensive care unit (ICU) stay. Methods: A multicenter prospective observational study was performed. Patient characteristics, disease severity, nutritional status, type of nutritional therapy and outcomes, and laboratory parameters were collected in a database. Statistical differences were analyzed according to the administration of IMN or other types of enteral formulas. Results: In total, 406 patients were included in the analysis, of whom 15.02% (61) received IMN. Univariate analysis showed that patients treated with IMN formulas received higher mean caloric and protein intake, and better 28-day survival (85.2% vs. 73.3%; p = 0.014. Unadjusted Hazard Ratio (HR): 0.15; 95% CI (Confidence Interval): 0.06−0.36; p < 0.001). Once adjusted for confounding factors, multivariate analysis showed a lower need for vasopressor support (OR: 0.49; 95% CI: 0.26−0.91; p = 0.023) and continuous renal replacement therapies (OR: 0.13; 95% CI: 0.01−0.65; p = 0.049) in those patients who received IMN formulas, independently of the severity of the disease. IMN use was also associated with higher protein intake during the administration of nutritional therapy (OR: 6.23; 95% CI: 2.59−15.54; p < 0.001), regardless of the type of patient. No differences were found in the laboratory parameters, except for a trend toward lower triglyceride levels (HR: 0.97; 95% CI: 0.95−0.99; p = 0.045). Conclusion: The use of IMN formulas may be associated with better outcomes (i.e., lower need for vasopressors and continuous renal replacement), together with a trend toward higher protein enteral delivery during the ICU stay. These findings may ultimately be related to their modulating effect on the inflammatory response in the critically ill. NCT Registry: 03634943.

Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

BACKGROUND & AIMS: The importance of artificial nutritional therapy is underrecognized, typically being considered an adjunctive rather than a primary therapy. We aimed to evaluate the influence of nutritional therapy on mortality in critically ill patients. METHODS: This multicenter prospective observational study included adult patients needing artificial nutritional therapy for >48 h if they stayed in one of 38 participating intensive care units for ≥72 h between April and July 2018. Demographic data, comorbidities, diagnoses, nutritional status and therapy (type and details for ≤14 days), and outcomes were registered in a database. Confounders such as disease severity, patient type (e.g., medical, surgical or trauma), and type and duration of nutritional therapy were also included in a multivariate analysis, and hazard ratios (HRs) and 95% confidence intervals (95%CIs) were reported. RESULTS: We included 639 patients among whom 448 (70.1%) and 191 (29.9%) received enteral and parenteral nutrition, respectively. Mortality was 25.6%, with non-survivors having the following characteristics: older age; more comorbidities; higher Sequential Organ Failure Assessment (SOFA) scores (6.6 ± 3.3 vs 8.4 ± 3.7; P < 0.001); greater nutritional risk (Nutrition Risk in the Critically Ill [NUTRIC] score: 3.8 ± 2.1 vs 5.2 ± 1.7; P < 0.001); more vasopressor requirements (70.4% vs 83.5%; P=0.001); and more renal replacement therapy (12.2% vs 23.2%; P=0.001). Multivariate analysis showed that older age (HR: 1.023; 95% CI: 1.008-1.038; P=0.003), higher SOFA score (HR: 1.096; 95% CI: 1.036-1.160; P=0.001), higher NUTRIC score (HR: 1.136; 95% CI: 1.025-1.259; P=0.015), requiring parenteral nutrition after starting enteral nutrition (HR: 2.368; 95% CI: 1.168-4.798; P=0.017), and a higher mean Kcal/Kg/day intake (HR: 1.057; 95% CI: 1.015-1.101; P=0.008) were associated with mortality. By contrast, a higher mean protein intake protected against mortality (HR: 0.507; 95% CI: 0.263-0.977; P=0.042). CONCLUSIONS: Old age, higher organ failure scores, and greater nutritional risk appear to be associated with higher mortality. Patients who need parenteral nutrition after starting enteral nutrition may represent a high-risk subgroup for mortality due to illness severity and problems receiving appropriate nutritional therapy. Mean calorie and protein delivery also appeared to influence outcomes. TRIAL REGISTRATION: ClinicaTrials.gov NCT: 03634943.

Spread of SARS-CoV-2 in hospital areas.

We performed a systematic sampling and analysis of airborne SARS-CoV-2 RNA in different hospital areas to assess viral spread. Systematic air filtration was performed in rooms with COVID-19 infected patients, in corridors adjacent to these rooms, to rooms of intensive care units, and to rooms with infected and uninfected patients, and in open spaces. RNA was extracted from the filters and real-time reverse transcription polymerase chain reaction was performed using the LightMix Modular SARS-CoV-2 E-gene. The highest occurrence of RNA was found in the rooms with COVID-19 patients (mean 2600 c/m3) and the adjacent corridor (mean 4000 c/m3) which was statistically significant more exposed (p < 0.01). This difference was related to the ventilation systems. As is commonly found in many hospitals, each of the rooms had an individual air inlet and outlet, while in the corridors these devices were located at the distance of every four rooms. There was a significant transfer of viruses from the COVID-19 patients' rooms to the corridors. The airborne SARS-CoV-2 RNA in the corridors of ICUs with COVID-19 patients or care rooms of uninfected patients were ten times lower, averages 190 c/m3 and 180 c/m3, respectively, without presenting significant differences. In all COVID-19 ICU rooms, patients were intubated and connected to respirators that filtered all exhaled air and prevented virus release, resulting in significantly lower viral concentrations in adjacent corridors. The results show that the greatest risk of nosocomial infection may also occur in hospital areas not directly exposed to the exhaled breath of infected patients. Hospitals should evaluate the ventilation systems of all units to minimize possible contagion and, most importantly, direct monitoring of SARS-CoV-2 in the air should be carried out to prevent unexpected viral exposures.

Dysphagia and mechanical ventilation in SARS-COV-2 pneumonia: It's real.

BACKGROUND & AIMS: Dysphagia can be a consequence of prolonged hospitalization in intensive care units (ICUs) due to severe SARS-CoV-2 pneumonia. This study aims at Identifying the risk factors for dysphagia in ICU patients with COVID-19 pneumonia requiring invasive mechanical ventilation, and at determining the frequency of postextubation dysphagia in this population. METHODS: Observational, descriptive, retrospective, cohort study of SARS-CoV-2 pneumonia patients admitted into the ICUs from March to May 2020. The Modified Viscosity Volume Swallowing Test (mV-VST) was used to screening for dysphagia during the first 48 h of extubation in patients requiring mechanical ventilation. Descriptive statistics, univariate and multivariate analyses were conducted. A logistic regression was applied to construct a predictive model of dysphagia. RESULTS: A total of 232 patients were admitted into the ICUs (age [median 60.5 years (95% CI: 58.5 to 61.9)]; male [74.1% (95% CI: 68.1 to 79.4)]; APACHE II score [median 17.7 (95% CI: 13.3 to 23.2)]; length of mechanical ventilation [median 14 days (95% CI: 11 to 16)]; prone position [79% (95% CI: 72.1 to 84.6)]; respiratory infection [34.5% (95% CI: 28.6 to 40.9)], renal failure [38.5% (95% CI: 30 to 50)])). 72% (167) of patients required intubation; 65.9% (110) survived; and in 84.5% (93) the mV-VST was performed. Postextubation dysphagia was diagnosed in 26.9% (25) of patients. APACHE II, prone position, length of ICU and hospital stay, length of mechanical ventilation, tracheostomy, respiratory infection and kidney failure developed during admission were significantly associated (p < 0.05) with dysphagia. Dysphagia was independently explained by the APACHE II score (OR: 1.1; 95% CI: 1.01 to 1.3; p = 0.04) and tracheostomy (OR: 10.2; 95% CI: 3.2 to 32.1) p < 0.001). The predictive model forecasted dysphagia with a good ROC curve (AUC: 0.8; 95% CI: 0.7 to 0.9). CONCLUSIONS: Dysphagia affects almost one-third of patients with SARS-COV-2 pneumonia requiring intubation in the ICU. The risk of developing dysphagia increases with prolonged mechanical ventilation, tracheostomy, and poorer prognosis on admission (worst APACHE II score).

Unmet needs, health policies, and actions during the COVID-19 pandemic: a report from six European countries.

PURPOSE: The United Nations (UN) has published a Policy Brief on the impact of the Coronavirus Disease 2019 (COVID-19) that identifies policies and responses to protect older adults. Our objective was to summarize actions, health policies and clinical guidelines adopted by six European countries (Belgium, France, Italy, Poland, Spain and United Kingdom) during the pandemic, and to assess the impact of national policies on reducing adverse effects of the COVID-19 pandemic in older populations. METHODS: Reports by geriatricians on the measures and actions undertaken by governmental institutions in each country between March and July 2020, as well as the role of primary care during the pandemic, covered three areas: (a) general health strategies related to the pandemic; (b) impact of COVID-19 on health inequity; and (c) initiatives and challenges for the COVID-19 pandemic and beyond. RESULTS: In the six countries, COVID-19 mortality in nursing homes ranged from 26 to 66%. Although all countries endorsed the World Health Organization general recommendations, the reports identified the lack of harmonized European guidelines and policies for nursing homes, with competencies transferred to national (or regional) governments. All countries restricted visits in nursing homes, but no specific action plans were provided. The role of primary care was limited by the centralization of the crisis in hospital settings. CONCLUSIONS: The older population has been greatly affected by COVID-19 and by the policies initiated to control its spread. The right to health and dignity are transgenerational; chronological age should not be the sole criterion in policy decisions.

Exposure to disinfection by-products in swimming pools and biomarkers of genotoxicity and respiratory damage - The PISCINA2 Study.

BACKGROUND: Swimming in pools is a healthy activity that entails exposure to disinfection by-products (DBPs), some of which are irritant and genotoxic. OBJECTIVES: We evaluated exposure to DBPs during swimming in a chlorinated pool and the association with short-term changes in genotoxicity and lung epithelium permeability biomarkers. METHODS: Non-smoker adults (N = 116) swimming 40 min in an indoor pool were included. We measured a range of biomarkers before and at different times after swimming: trihalomethanes (THMs) in exhaled breath (5 min), trichloroacetic acid (TCAA) in urine (30 min), micronuclei in lymphocytes (1 h), serum club cell protein (CC16) (1 h), urine mutagenicity (2 h) and micronuclei in reticulocytes (4 days in a subset, N = 19). Several DBPs in water and trichloramine in air were measured, and physical activity was extensively assessed. We estimated interactions with polymorphisms in genes related to DBP metabolism. RESULTS: Median level of chloroform, brominated and total THMs in water was 37.3, 9.5 and 48.5, µg/L, respectively, and trichloramine in air was 472.6 µg/m3. Median exhaled chloroform, brominated and total THMs increased after swimming by 10.9, 2.6 and 13.4, µg/m3, respectively. Creatinine-adjusted urinary TCAA increased by 3.1 µmol/mol. Micronuclei in lymphocytes and reticulocytes, urine mutagenicity and serum CC16 levels remained unchanged after swimming. Spearman correlation coefficients showed no association between DBP exposure and micronuclei in lymphocytes, urine mutagenicity and CC16. Moderate associations were observed for micronuclei in reticulocytes and DBP exposure. CONCLUSIONS: The unchanged levels of the short-term effect biomarkers after swimming and null associations with personal estimates of exposure to DBPs suggest no measurable effect on genotoxicity in lymphocytes, urine mutagenicity and lung epithelium permeability at the observed exposure levels. The moderate associations with micronuclei in reticulocytes require cautious interpretation given the reduced sample size.

Vehicle interior air quality conditions when travelling by taxi.

Vehicle interior air quality (VIAQ) was investigated inside 14 diesel/non-diesel taxi pairs operating simultaneously and under normal working conditions over six weekday hours (10.00-16.00) in the city of Barcelona, Spain. Parameters measured included PM10 mass and inorganic chemistry, ultrafine particle number (N) and size, lung surface deposited area (LDSA), black carbon (BC), CO2, CO, and a range of volatile organic compounds (VOCs). Most taxi drivers elected to drive with windows open, thus keeping levels of CO2 and internally-generated VOCs low but exposing them to high levels of traffic-related air pollutants entering from outside and confirming that air exchange rates are the dominant influence on VIAQ. Median values of N and LDSA (both sensitive markers of VIAQ fluctuations and likely health effects) were reduced to around 104 #/cm3 and < 20 µm2/cm3 respectively under closed conditions, but more than doubled with windows open and sometimes approached 105 #/cm3 and 240 µm2/cm3. In exceptional traffic conditions, transient pollution peaks caused by outside infiltration exceeded N = 106 #/cm3 and LDSA= 1000 µm2/cm3. Indications of self-pollution were implicated by higher BC and CO levels, and larger UFP sizes, measured inside diesel taxis as compared to their non-diesel pair, and the highest concentrations of CO (>2 ppm) were commonly associated with older, high-km diesel taxis. Median PM10 concentrations (67 µg/m3) were treble those of urban background, mainly due to increased levels of organic and elemental carbon, with source apportionment calculations identifying the main pollutants as vehicle exhaust and non-exhaust particles. Enhancements in PM10 concentrations of Cr, Cu, Sn, Sb, and a "High Field Strength Element" zircon-related group characterised by Zr, Hf, Nb, Y and U, are attributed mainly to the presence of brake-derived PM. Volatile organic compounds display a mixture which reflects the complexity of traffic-related organic carbon emissions infiltrating the taxi interior, with 2-methylbutane and n-pentane being the most abundant VOCs, followed by toluene, m-xylene, o-xylene, 1,2,4-trimethylbenzene, ethylbenzene, p-xylene, benzene, and 1,3,5-trimethylbenzene. Internally sourced VOCs included high monoterpene concentrations from an air freshener, and interior off-gassing may explain why the youngest taxi registered the highest content of alkanes and aromatic compounds. Carbon dioxide concentrations quickly climbed to undesirable levels (>2500 ppm) under closed ventilation conditions and could stay high for much of the working day. Taxi drivers face daily occupational exposure to traffic-related air pollutants and would benefit from a greater awareness of VIAQ issues, notably the use of ventilation, to encourage them to minimise possible health effects caused by their working environment.

Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial.

BACKGROUND AND AIMS: Lack of achievement of secondary prevention objectives in patients with ischaemic heart disease remains an unmet need in this patient population. We aimed at evaluating the six-month efficacy of an intensive lipid-lowering intervention, coordinated by nurses and implemented after hospital discharge, in patients hospitalized for an ischaemic heart disease event. METHODS: Randomized controlled trial, in which a nurse-led intervention including periodic follow-up, serial lipid level controls, and subsequent optimization of lipid-lowering therapy, if appropriate, was compared with standard of care alone in terms of serum lipid-level control at six months after discharge. RESULTS: The nurse-led intervention was associated with an improved management of low-density lipoprotein (LDL) cholesterol levels compared with standard of care alone: LDL cholesterol levels ⩽100 mg/dL were achieved in 97% participants in the intervention arm as compared with 67% in the usual care arm ( p value <0.001), the LDL cholesterol ⩽70 mg/dL target recommended by the 2016 European Society of Cardiology guidelines was achieved in 62% vs. 37% participants ( p value 0.047) and the LDL cholesterol reduction of ⩾50% recommended by the American College of Cardiology/American Heart Association in 2013 was achieved in 25.6% of participants in the intervention arm as compared with 2.6% in the usual care arm ( p value 0.007). The intervention was also associated with improved blood pressure control among individuals with hypertension. CONCLUSIONS: Our findings highlight the opportunity that nurse-led, intensive, post-discharge follow-up plans may represent for achieving LDL cholesterol guideline-recommended management objectives in patients with ischaemic heart disease. These findings should be replicated in larger cohorts.

Influence of electronic cigarette vaping on the composition of indoor organic pollutants, particles, and exhaled breath of bystanders.

The changes of particles and organic pollutants in indoor atmospheres as consequence of vaping with electronic cigarettes have been analyzed. Changes in the composition of volatile organic compounds (VOCs) in exhaled breath of non-smoking volunteers present in the vaping environments have also been studied. The exposure experiments involved non-vaping (n = 5) and vaping (n = 5) volunteers staying 12 h together in a room (54 m2) without external ventilation. The same experiment was repeated without vaping for comparison. Changes in the distributions of particles in the 8-400 nm range were observed, involving losses of nucleation-mode particles (below 20 nm) and increases of coagulation processes leading to larger size particles. In quantitative terms, vaping involved doubling the indoor concentrations of particles smaller than 10 µm, 5 µm, and 1 µm observed during no vaping. The increase of particle mass concentrations was probably produced from bulk ingredients of the e-liquid exhaled by the e-cigarette users. Black carbon concentrations in the indoor and outdoor air were similar in the presence and absence of electronic cigarette emissions. Changes in the qualitative composition of PAHs were observed when comparing vaping and non-vaping days. The nicotine concentrations were examined separately in the gas and in the particulate phases showing that most of the differences between both days were recorded in the former. The particulate phase should therefore be included in nicotine monitoring during vaping (and smoking). The concentration increases of nicotine and formaldehyde were small when compared with those described in other studies of indoor atmospheres or health regulatory thresholds. No significant changes were observed when comparing the concentrations of exhaled breath in vaping and no vaping days. Even the exhaled breath nicotine concentrations in both conditions were similar. As expected, toluene, xylenes, benzene, ethylbenzene, and naphthalene did not show increases in the vaping days since combustion was not involved.

Atmospheric pattern of volatile organochlorine compounds and hexachlorobenzene in the surroundings of a chlor-alkali plant.

The outdoor atmospheric distributions of chlorinated volatile organic compounds (VOCs) from locations receiving the emissions of a chlor-alkali plant have been studied. Trichloroethylene and tetrachloroethylene (medians 2.4 µg/m3 and 1.7 µg/m3, respectively) were the most abundant compounds, which was in accordance with the production processes from these installations. The concentrations of trichlorofluoromethane, median 1.6 µg/m3, are rather similar to the average levels described in general in the troposphere and cannot be attributed to this specific source. Several by-products involving dichloroacetylene, carbon tetrachloride, hexachloroethane, hexachlorobutadiene, trans-1H-pentachloro-1,3-butadiene, 2H-pentachloro-1,3-butadiene, cis-1H-pentachloro-1,3-butadiene, tetrachloro- and trichloro-butadienes and hexachlorobenzene were also identified. Some of these compounds, e.g. carbon tetrachloride, chloroform and tetrachloroethane, could also have been manufactured during some periods. The occurrence of these manufactured compounds and by-products in the atmosphere could also reflect, at least in part, volatilization during the extraction of previously discharged chlor-alkali residues developed within the environmental restoration program of the Flix water reservoir. In this respect, the tri-, tetra- and pentachloro-1,3-butadienes could also originate from microbial transformation in the solid deposits accumulated in the water reservoir which were volatilized after extraction. Among all identified VOCs, trichloroethylene showed the highest health risks considering the measured airborne concentrations and the WHO and USEPA recommendations.

Environmental and personal determinants of the uptake of disinfection by-products during swimming.

BACKGROUND: Trihalomethanes (THMs) in exhaled breath and trichloroacetic acid (TCAA) in urine are internal dose biomarkers of exposure to disinfection by-products (DBPs) in swimming pools. OBJECTIVE: We assessed how these biomarkers reflect the levels of a battery of DBPs in pool water and trichloramine in air, and evaluated personal determinants. METHODS: A total of 116 adults swam during 40min in a chlorinated indoor pool. We measured chloroform, bromodichloromethane, dibromochloromethane and bromoform in exhaled breath and TCAA in urine before and after swimming, trichloramine in air and several DBPs in water. Personal determinants included sex, age, body mass index (BMI), distance swum, energy expenditure, heart rate and 12 polymorphisms in GSTT1, GSTZ1 and CYP2E1 genes. RESULTS: Median level of exhaled total THMs and creatinine adjusted urine TCAA increased from 0.5 to 14.4µg/m(3) and from 2.5 to 5.8µmol/mol after swimming, respectively. The increase in exhaled brominated THMs was correlated with brominated THMs, haloacetic acids, haloacetonitriles, haloketones, chloramines, total organic carbon and total organic halogen in water and trichloramine in air. Such correlations were not detected for exhaled chloroform, total THMs or urine TCAA. Exhaled THM increased more in men, urine TCAA increased more in women, and both were affected by exercise intensity. Genetic variants were associated with differential increases in exposure biomarkers. CONCLUSION: Our findings suggest that, although affected by sex, physical activity and polymorphisms in key metabolizing enzymes, brominated THMs in exhaled breath could be used as a non-invasive DBP exposure biomarker in swimming pools with bromide-containing source waters. This warrants confirmation with new studies.

A rapid method for the chromatographic analysis of volatile organic compounds in exhaled breath of tobacco cigarette and electronic cigarette smokers.

A method for the rapid analysis of volatile organic compounds (VOCs) in smoke from tobacco and electronic cigarettes and in exhaled breath of users of these smoking systems has been developed. Both disposable and rechargeable e-cigarettes were considered. Smoke or breath were collected in Bio-VOCs. VOCs were then desorbed in Tenax cartridges which were subsequently analyzed by thermal desorption coupled to gas chromatography-mass spectrometry. The method provides consistent results when comparing the VOC compositions from cigarette smoke and the equivalent exhaled breath of the smokers. The differences in composition of these two sample types are useful to ascertain which compounds are retained in the respiratory system after tobacco cigarette or e-cigarette smoking. Strong differences were observed in the VOC composition of tobacco cigarette smoke and exhaled breath when comparing with those of e-cigarette smoking. The former involved transfers of a much larger burden of organic compounds into smokers, including benzene, toluene, naphthalene and other pollutants of general concern. e-Cigarettes led to strong absorptions of propylene glycol and glycerin in the users of these systems. Tobacco cigarettes were also those showing highest concentration differences between nicotine concentrations in smoke and exhaled breath. The results from disposable e-cigarettes were very similar to those from rechargeable e-cigarettes.

Influence of physical activity in the intake of trihalomethanes in indoor swimming pools.

This study describes the relationship between physical activity and intake of trihalomethanes (THMs), namely chloroform (CHCl3), bromodichloromethane (CHCl2Br), dibromochloromethane (CHClBr2) and bromoform (CHBr3), in individuals exposed in two indoor swimming pools which used different disinfection agents, chlorine (Cl-SP) and bromine (Br-SP). CHCl3 and CHBr3 were the dominant compounds in air and water of the Cl-SP and Br-SP, respectively. Physical exercise was assessed from distance swum and energy expenditure. The changes in exhaled breath concentrations of these compounds were measured from the differences after and before physical activity. A clear dependence between distance swum or energy expenditure and exhaled breath THM concentrations was observed. The statistically significant relationships involved higher THM concentrations at higher distances swum. However, air concentration was the major factor determining the CHCl3 and CHCl2Br intake in swimmers whereas distance swum was the main factor for CHBr3 intake. These two causes of THM incorporation into swimmers concurrently intensify the concentrations of these compounds into exhaled breath and pointed to inhalation as primary mechanism for THM uptake. Furthermore, the rates of THM incorporation were proportionally higher as higher was the degree of bromination of the THM species. This trend suggested that air-water partition mechanisms in the pulmonary system determined higher retention of the THM compounds with lower Henry's Law volatility constants than those of higher constant values. Inhalation is therefore the primary mechanisms for THM exposure of swimmers in indoor buildings.

Variabilidad de la composición corporal medida con bioimpedanciometría eléctrica según condiciones de realización: influencia del ayuno y del reposo / Variability in bioelectrical impedance assessment of body composition depending on measurement conditions influence of fast and rest

Introducción: La bioimpedanciometría eléctrica (BIA) constituye una de las principales herramientas para evaluar la composición corporal. Aunque se recomienda la realización de la BIA en condiciones de ayuno y 60 minutos de reposo, en la práctica asistencial no siempre es posible garantizar su cumplimiento. Objetivos: Determinar la fiabilidad de los parámetros de composición corporal estimados por BIA bajo diferentes condiciones fisiológicas: ayuno + reposo, ayuno + no-reposo y no-ayuno + no- reposo en voluntarios sanos. Metodología: Estudio transversal en 25 voluntarios sanos entre 18 y 34 años de edad (12 hombres, 13 mujeres). Se realizó una BIA en tres condiciones diferentes: 1) ayuno + reposo de 60 minutos en decúbito supino (gold standard), 2) ayuno + no reposo y 3) no ayuno + no reposo. Los parámetros recogidos fueron: masa magra y masa grasa (Kg) y agua corporal (litros y en porcentaje del peso corporal). Para valorar la concordancia entre las diferentes mediciones, se utilizó el coeficiente de correlación intraclase (CCI) Resultados: En comparación con el gold standard, la diferencia de medias de la masa magra en la condición de ayuno + no-reposo, fue -0.15 (DE 1.44) en los hombres y 0.98 (DE 1.36) en mujeres; la masa grasa disminuyó 0.06 (DE 1.55) en hombres y 0.82 (DE 1.5) en mujeres; el CCI osciló entre 0.826-0.995 en todas las comparaciones. En la condición de no-ayuno + no reposo, la masa magra disminuyó una media 0.05 (DE 0.33) en los hombres y en las mujeres se incrementó 0.62 (DE 0.46); la masa grasa disminuyó 0.57 (DE 0.82) en hombres y 0.46 (DE 0.60) en mujeres; y el CCI osciló entre 0.942 y 0.999, excepto en el agua corporal en hombres que fue de 0.340. Discusión: Las diferencias observadas en los parámetros obtenidos por BIA al comparar la condición gold standard (ayuno + reposo) con las otras condiciones (ayuno + no reposo y no-ayuno + no-reposo), aunque significativas, son de escasa magnitud. En la práctica clínica, la valoración de parámetros de composición corporal permite tomar decisiones a la hora de planificar el tratamiento en pacientes con desacondicionamiento físico. Conclusiones: La fiabilidad de los parámetros obtenidos por BIA entre diferentes condiciones fisiológicas de ayuno y reposo es excelente (CCI >0.75) en adultos sanos entre 19 y 34 años. Si bien las recomendaciones generales sobre el uso de los dispositivos de BIA se deben mantener, las condiciones de realización podrían modificarse en función del contexto asumiendo una diferencia de pequeña magnitud y escasa relevancia clínica (AU)

Background: Bioelectrical Impedance Assessment (BIA) is one of the main tools to measure body composition. BIA is recommended in fasting and after 60 minutes of rest; however, this cannot always be guaranteed in healthcare practice. Objectives: To establish the reliability of the body composition parameters assessed with BIA under different physiological conditions: fast + rest, fast + no-rest and no-fast + no-rest in healthy volunteers. Methods: Transversal study including 25 healthy volunteers aged 18-34 (12 men, 13 women). A BIA was performed under three different conditions: 1) fast + 60 minute rest in cubito supino (gold standard), 2) fast + no rest and 3) no fast + no rest. The collected parameters were: lean mass and fat mass (Kg) and body water (in liters and as body weight percentage). The intraclass correlation coefficient (ICC) was applied for the assessment of concordance within the different measurements. Results: Compared to the gold standard, the difference in lean mass means in the condition of fast + no-rest, was -0.15 (DE 1.44) in men and 0.98 (DE 1.36) in women; fat mass decreased in 0.06 (DE 1.55) in men and 0.82 (DE 1.5) in women; ICC ranged between 0.826-0.995 in all comparisons. In the condition of no-fast + no rest, lean mass decreased an average of 0.05 (DE 0.33) in men and it increased 0.62 (DE 0.46) in women; fat mass decreased 0.57 (DE 0.82) in men and 0.46 (DE 0.60) in women; ad ICC ranged between 0.942 and 0.999, except in body water in men, where it was 0.340. Discussion: Although relevant, the differences observedin parameters from BIA when comparing the gold standard condition (fast + rest) with the other conditions (fast + no-rest and no-fast + no-rest) are of little magnitude. In clinical practice, the assessment of body composition allows to take decisions when planning treatment for patients with a poor physical condition. Conclusions: The reliability of the parameters acquired via BIA within different physiological conditions of fast and rest is excellent (CCI >0.75) in healthy adults aged 19-34. Although general recommendations on theuse of BIA devices must be kept in place, the conditions of the performance could be modified according to the context and assuming a small difference of little clinical relevance (AU)

Guía española de la EPOC (GesEPOC). Actualización 2014 / Spanish Guideline for COPD (GesEPOC). Update 2014

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Trihalomethanes in chlorine and bromine disinfected swimming pools: air-water distributions and human exposure.

This first study of trihalomethanes (THMs) in swimming pools using bromine agents for water disinfection under real conditions shows that the mixtures of these compounds are largely dominated by bromoform in a similar process as chloroform becomes the dominant THM in pools disinfected with chlorine agents. Bromoform largely predominates in air and water of the pool installations whose concentration changes are linearly correlated. However, the air concentrations of bromoform account for about 6-11% of the expected concentrations according to theoretical partitioning defined by the Henry law. Bromoform in exhaled air of swimmers is correlated with the air concentrations of this disinfectant by-product in the pool building. Comparison of the THM exhaled air concentrations between swimmers and volunteers bathing in the water without swimming or standing in the building outside the water suggest that physical activity enhance exposure to these disinfectant by-products. They also indicate that in swimming pools, besides inhalation, dermal absorption is a relevant route for the incorporation of THMs, particularly those with lower degree of bromination.