Timing of parenteral nutrition is associated with adequacy of nutrient delivery and anthropometry in critically ill children: A single-center study.

BACKGROUND: The optimal timing of supplemental parenteral nutrition (PN) use in the pediatric intensive care unit (ICU) is unclear. We aimed to describe patterns of PN use in the ICU and the association between the timing of PN initiation and macronutrient delivery and anthropometry. METHODS: We enrolled patients (aged <18 years) with an ICU stay >3 days were started on PN in the ICU. Initiation within 48 hours of admission was deemed as early, and duration <5 days was deemed as short. We used multivariable analysis to examine the association between PN timing and macronutrient delivery adequacy (percentage of the prescribed target that was actually delivered) and weight-for-age z-score (WAZ) over hospital stay. RESULTS: Ninety-five patients were included. Median (interquartile range [IQR]) time to initiate PN was 4 (1, 6) days, and in 33%, PN was initiated early. Median (IQR) PN duration was 8 (5, 14) days, and in 16.8%, duration was short. Median (IQR) adequacies for total energy and protein delivery were 55% (40, 74) and 72% (44, 81) in the early PN group compared with 29% (3, 50) and 31% (4, 47), respectively, in the late PN group (P < .001). The late PN group had a 0.50-unit greater decline in mean WAZ compared with the early PN group (95% CI, 0.11-0.89; P = .012). CONCLUSION: Late PN initiation was associated with significantly lower adequacy of macronutrient delivery and greater decline in WAZ in critically ill children. The relationship between PN timing patient outcomes must be further examined.

Retrospective analysis of eligibility for denosumab in patients presenting with osteoporotic fractures and renal impairment treated by orthogeriatric service at Middlemore Hospital.

BACKGROUND: Little is known about the prevalence of renal impairment in patients presenting with osteoporotic fractures contraindicating bisphosphonate use in New Zealand, and their eligibility to denosumab. AIM: To assess the prevalence of renal impairment contraindicating bisphosphonate use in older adults presenting with osteoporotic fractures, differences in demographic variables between those with renal impairment and those who do not, and finally to assess eligibility for denosumab based on the current PHARMAC special authority criteria. METHOD: All patients 65 years and older with osteoporotic fractures treated by inpatient orthogeriatric service (IOS) and the outpatient fracture liaison service (FLS) at Middlemore Hospital between 1 February to 31 April 2019 were assessed. Following data was retrospectively collected-age, sex, ethnicity, preadmission residential status, type of acute osteoporotic fractures, history of previous osteoporotic fractures, cognitive impairment and its severity, history of falls, previous dual-energy x-ray absorptiometry (DEXA) scan and the worst documented T-scores over total hip, neck of femur or L1-4 spine and previous funded anti-resorptive therapy use. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault formula based on the ideal body weight according to the recorded height and serum creatinine level at the time of patient's presentation. Patients with CrCl below 35ml/min were assigned to the renal group, and those with CrCl above 35ml/min to the non-renal group. Current PHARMAC criteria for denosumab was used to assess the eligibility in the renal group. RESULTS: Total of 190 patients (102 IOS and 88 FLS) were assessed. Thirty-four patients (17.9%) had renal impairment with CrCl less than 35ml/min and were assigned to the renal group. There were no statistically significant differences in demographic variables between the renal and the non-renal group other than for age, where the renal group was significantly older (85.4 vs 77.5 years, P-value <0.0001). Two out of 34 patients were eligible for denosumab. Reasons for ineligibility to denosumab were as follows; not meeting the definition of severe established osteoporosis due to presenting with their first ever osteoporotic fracture (64.7%), no previous DEXA scans to quantify their bone mineral density (11.8%), measured bone mineral density T-score above -2.5 (5.9%); and no preceding treatment with a funded anti-resorptive therapy for at least 12 months prior to their osteoporotic fracture (11.8%). CONCLUSION: Considerable number of patients aged 65 years and older with osteoporotic fractures also had renal impairment contraindicating the use of bisphosphonates. There were no significant differences in demographic variables between the renal and non-renal group other than for age. Majority of patients in the renal group were ineligible for denosumab based on the current special authority criteria. These results highlight the need for further review and revision of the current PHARMAC criteria to improve access to denosumab in older adults with renal impairment and osteoporotic fractures.

Comparison of peritoneal dialysis catheter insertion techniques: Peritoneoscopic, radiological and laparoscopic : A single-centre study.

BACKGROUND: Our centre introduced peritoneoscopic insertion of peritoneal dialysis (PD) catheter by nephrologists as a new method in August 2009 for its potential benefits. AIM: The aim of this study was to compare perioperative complications and catheter survival of three techniques: peritoneoscopic, surgical and radiological techniques within a single dialysis centre. METHOD: This study used retrospective analysis of all PD catheter inserted from 1 August 2009 to 31 July 2013 within Counties Manukau DHB, Auckland, New Zealand. RESULTS: During the study period, 293 PD catheters were inserted, 84 (29%) peritoneoscopic (P), 140 (48%) surgical (S) and 69 (23%) radiological (R). Total duration of follow-up was 5848 catheter-months, with median follow-up of 17 months. There was no difference in perioperative exit-site infections and overall early infections. There was however increased overall perioperative complications in P compared with R (HR 2.08; P < 0.05), predominantly from catheter removal within 60 days. Although there was no difference observed in first catheter 1-year and overall survival between insertion techniques, there was poorer complication-free survival comparing P to S (HR 1.82, P = 0.001) but not to R. Analyses of the latter cohort of P confirmed improvement in catheter survival compared with an earlier cohort and to other insertion techniques. CONCLUSION: Peritoneoscopic PD catheter insertion is demonstrated to be a suitable alternative technique. As with any new procedure, 'learning curve' effects and development of operator expertise need to be taken into consideration.

Ethnic differences in creatinine kinetics in a New Zealand end-stage kidney disease cohort.

BACKGROUND: Recent data have suggested that glomerular filtration rate (GFR) is better predicted in New Zealand (NZ) Maori and Pacific People using the equations for Black people that predict higher GFR for any given serum creatinine. We hypothesized that this might be due to a higher rate of creatinine generation in NZ Maori and Pacific People. AIM: To compare creatinine kinetics between different ethnic groups in a cohort of NZ peritoneal dialysis patients. METHODS: In this retrospective single-centre observational study, creatinine kinetics in 181 patients were determined from timed serum samples, peritoneal dialysate and urine collections between 1 October 2004 and 31 July 2011. Ethnicity was classified as Asian, NZ European, NZ Maori and Pacific People. RESULTS: A total of 799 samples from 181 patients were analysed: 194 in Asians, 127 in NZ Europeans, 268 in NZ Maori, 207 in Pacific People. Pacific People had the highest serum creatinine and lean body mass, and the highest creatinine generation rate at 1349 mg/day, compared with 1049 for Asians, 1186 for NZ Europeans and 1094 for NZ Maori (P = 0.0001). After adjustment for confounding factors, Pacific People had a greater creatinine generation by 140 mg/day compared with NZ Europeans (P = 0.047). CONCLUSION: Pacific People on peritoneal dialysis in NZ have higher serum creatinine, lean body mass and creatinine generation than other ethnic groups. This is consistent with previous observations that equations for predicting GFR in Black people may have increased accuracy in some Australasian non-White non-Asian populations.

An uncommon complication of infective bacterial endocarditis.

Coronary artery septic embolisation resulting in cardioembolic myocardial infarction (MI) is a rare complication of bacterial infective endocarditis (IE), representing <1% of complications related to IE. Diagnosis requires a combination of high clinical suspicion, coronary angiography, echocardiography and cultures of peripheral blood and/or embolic material. The associated mortality rate remains high despite early diagnosis. Optimal interventional therapy is unknown with published international experience over the past two decades limited to very small case series and individual case reports. We present a case of ST elevation MI resulting from coronary artery septic embolisation with an accompanying comprehensive review of the literature.

Polycationic lipids inhibit the pro-inflammatory response to LPS.

Lipopolysaccharide (LPS) is a major component of the outer membrane of Gram-negative bacteria. As such, it signals monocytes, macrophages and neutrophils to up-regulate phagocytic functions and to release pro-inflammatory cytokines. Despite the established role of CD14 as the main LPS receptor, the precise nature of the LPS signalling complex and its compartmentalization remain unknown. Interactions of LPS with other cell surface molecules such as TLR-4 and MD-2, and its subsequent internalization are required for LPS signalling. Here, we show that the polycationic lipid LipoFectamine causes inhibition of the LPS-induced MAPK activation and lack of pro-inflammatory cytokine production, despite proper localization of CD14 within lipid rafts and massive LPS internalization. The ability of LipoFectamine to inhibit LPS induced pro-inflammatory responses may be due to uncoupling of CD14 from TLR-4/MD-2 in the LPS signalling complex of mouse macrophages/microglial cells, as suggested by inhibition of LPS-induced concomitant internalization of these surface molecules. Thus, LipoFectamine may be a useful tool to dissect the molecular interactions leading to LPS signalling, and identifies a potential therapeutic strategy for LPS clearance.