Objetivo: trata-se de revisão integrativa da literatura realizada com o objetivo de identificar os estudos primários que abordam os eventos adversos relacionados à sonda nasogástrica / nasoentérica (SNG/SNE) em pacientes adultos. Método: a busca foi realizada no mês de abril de 2017 nas bases de dados PubMed, CINAHL, LILACS, EMBASE e Scopus. Para realizar a busca foram utilizadas palavras-chave e encontradas 1.020 citações. Destas, 988 artigos foram excluídos a partir da leitura de títulos e resumos. Em seguida, procedeu-se a leitura, na íntegra, de 32 artigos, dos quais 12 foram excluídos. Logo, um total de 20 artigos foram incluídos no estudo. Foi realizada, também, busca manual nas referências dos artigos incluídos com o intuito de encontrar estudos que não foram recuperados anteriormente nas bases de dados supracitadas. Foram obtidos 84 artigos, dos quais 30 foram excluídos, a partir da leitura de títulos e resumos. Dos 54 artigos recuperados, quatro foram excluídos após leitura na íntegra e um artigo durante a extração dos dados. Resultados: para esta revisão integrativa, foram incluídos um total de 69 artigos. Os dados foram analisados e posteriormente classificados em duas categorias principais que evidenciaram os eventos adversos relacionados ao uso de SNG/SNE: incidentes mecânicos (complicações respiratórias, complicações no esôfago ou faringe, obstrução da sonda, perfuração intestinal, perfuração intracraniana e saque não planejado da sonda) e outros incidentes (lesão por pressão relacionada à fixação e conexão errada). A maior parte dos artigos recuperados foi incluída na subcategoria \"complicações respiratórias\" devido ao posicionamento inadequado da extremidade distal da sonda no trato respiratório, o que resultou em pneumotórax e/ou óbito. Outros eventos adversos estavam relacionados à obstrução da sonda, perda da mobilidade das cordas vocais, perfuração intestinal com consequente infecção, lesão na pele e mucosas, e queimadura corporal devido à desconexão. Conclusão: os resultados sintetizados nesta revisão permitem que os profissionais da saúde, especialmente os da enfermagem, reflitam sobre a segurança dos pacientes em uso de SNG/SNE e que repensem a maneira como as sondas estão sendo manuseadas na prática clínica / Objective: an integrative literature review was developed to identify the primary studies on the adverse events related to nasogastric / nasoenteral tubes (NGT/NET) in adult patients. Method: the search was undertaken in April 2017 in the databases PubMed, CINAHL, LILACS, EMBASE and Scopus. Keywords were used for the search and 1,020 citations were found. After reading titles and abstract, 988 of these articles were excluded. Next, 32 articles were fully read, 12 of which were excluded. Hence, in total, 20 articles were included in the study. In addition, a manual search was undertaken in the references of the included articles, aiming to find studies that had not been retrieved earlier in the abovementioned databases. Eighty-four articles were found, 30 of which were excluded after reading the titles and abstracts. Of the 54 retrieved articles, four were excluded after reading the full version and one article during the extraction of the data. Results: for this integrative review, in total, 69 articles were included. The data were analyzed and then classified in two main categories that evidenced the adverse events related to the use of NGT/NET: mechanic incidents (respiratory complications, esophageal or pharyngeal complications, tube obstruction, intestinal perforation, intracranial perforation and unplanned tube withdrawal) and other incidents (wrong connection and fixationrelated pressure ulcer). Most of the articles were included in the subcategory \"respiratory complications\" due to improper positioning of the distal end of the tube in the respiratory tract, resulting in pneumothorax and/or death. Other adverse events were related to tube obstruction, loss of vocal chord mobility, intestinal perforation with consequent infection, skin and mucous membrane ulcers, and body burns due to detachment. Conclusion: based on the results synthesized in this review, health professionals, especially in nursing, can reflect on the safety of patients using NGT/NET and reconsider the manipulation of the tubes in clinical practice

Introducción: La hemorragia digestiva alta (HDA) es una de las emergencias más frecuentes en medicina. Parte de su abordaje incluye la realización de una segunda endoscopia de control programada llamada “second look” (SL) con el propósito de reducir la incidencia de resangrado. No obstante, existe controversia en cuando su indicación y utilidad. Objetivo: Evaluar la efectividad del SL en la prevención del resangrado intrahospitalario en pacientes adultos con HDA no variceal. Métodos: Se llevó a cabo un estudio de cohorte retrospectivo sobre 1 144 pacientes con diagnóstico de HDA admitidos en la Unidad de Hemorragia Digestiva de un centro de referencia de la Seguridad Social en Lima, Perú; durante los años 2012 y 2014. La variable de respuesta fue el resangrado y la variable de exposición fue la programación a SL. Además se midió la hemoglobina al ingreso, comorbilidades, trasfusión de paquetes globulares y variables endoscópicas. Se calculó la incidencia acumulada (IA), riesgo relativo (RR), efectividad y mediante un modelo lineal generalizado de familia Poisson link log con errores estándar robustos se estimaron razones de tasas de incidencia (RTI). Resultados: La IA global de resangrado fue de 24,48% (n=280). Se encontró diferencia significativa entre las incidencias acumuladas (IA) entre el grupo de SL y el grupo de control (11,7 % vs 29,0 %, respectivamente, p<0,01). El RR fue 0,40 (IC95%:0,29-0,56) y la efectividad fue de 59,81% (IC95%: 44,17-71,08). En los modelos de regresión también se encontró una disminución de las tasas de incidencia tanto en el modelo crudo (RTI: 0,34 IC95%: 0,24-0,49), como en el modelo ajustado con diferencia estadística significativa entre los sometidos y no sometidos a SL (RTI: 0,12 IC95%: 0,08-0,18), por las variables asociadas con el resangrado (RTI: 0,21 IC95%: 0,15-0,30) y por las variables que cumplían los criterios clásicos de confusión (RTI: 0,12 IC95%: 0,08-0,18). Conclusiones: El SL es efectivo en la prevención de resangrado intrahospitalario en pacientes adultos con HDA en un hospital de referencia nacional. / Background: Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies. Part of its approach includes performing a second endoscopy, known as second look (SL). However, its indications and usefulness are controversial. Objectives: To evaluate the effectiveness of SL in preventing nosocomial rebleeding in adult patients with non-variceal upper gastrointestinal bleeding. Methods: A retrospective cohort of 1144 patients diagnosed with UGIB admitted at a Digestive Bleeding Unit of a reference center for Social Security in Lima, Peru was performed; during the years 2012 and 2014. The response variable was rebleeding and the exposure variable was programmed SL. Besides hemoglobin on admission, comorbidities, blood transfusion and endoscopic variables were measured. The cumulative incidence, relative risk (RR) and effectiveness were calculated, and using a generalized linear model of the Poisson family link log with robust standard errors, incidence rate ratios (IRR) were estimated. Results: The cumulative incidence rebleeding overall was 24.48% (n = 280). Significant difference between the cumulative incidences (IA) between the SL group and the control group (11.7% vs 29.0%, respectively, p <0.01) was found. The RR was 0.40 (95% CI 0.29 - 0.56) .The calculated effectiveness was 59.81% (95% CI: 44.17 - 71.08). The regression models also found a decrease in incidence in both crude model (IRR: 0.34 95% CI 0.24 to 0.49) and in the adjusted models. The first model was adjusted for variables with statistically significant differences between exposed and unexposed (IRR: 0.12 95% CI 1.8 to 0.18), the second was adjusted for variables that were significantly associated with rebleeding (IRR 0.21 95% CI 0.15-0.30). The third model was adjusted for variables that met classical criteria of confusion (IRR: 0.12 95% CI 0.08 to 0.18). / Tesis

Publicación a texto completo no autorizada por el autor / Determina los factores predictores de la evolución clínica en pacientes con HDA por úlcera péptica atendidos en el Servicio de Emergencia del Hospital Nacional Dos de Mayo entre enero 2009 y diciembre 2011. Se realizó un estudio observacional, analítico, transversal y retrospectivo. Se revisaron las historias clínicas de pacientes atendidos en el Servicio de Emergencia del Hospital Nacional Dos de Mayo con diagnóstico principal de HDA entre enero 2009 y diciembre 2011. Se vieron un total de 403 casos. La prevalencia hospitalaria de ulcera péptica según diagnóstico endoscópico en el Hospital Nacional Dos de Mayo fue de 52,3%; siendo la media de edad de 54,39 ± 14,067. Predominó el sexo masculino, los pacientes con empleo y solteros. Con respecto al estado clínico, la mayoría de pacientes ingresaron hemodinámicamente estables, presentándose en estado de shock solo el 4%. Se realizó tratamiento endoscópico en 32,6%, encontrándose en su mayoría el diagnóstico de úlcera gástrica. Se requirió terapia transfusional en emergencia para 31,9% de la población, mientras que 11,9% recibió terapia transfusional en hospitalización. 4,4% de la población estudiada necesitó tratamiento quirúrgico, 20,9% presentó resangrado; se reportaron 8 casos letales, lo cual significó el 1.98%. Se encontró como factores predictores de la morbilidad y mortalidad de la HDA a la presencia de enfermedades concomitantes (OR: 1.6; IC: 1.03-2.17) y edad mayor de 60 años (OR: 1.32; IC: 1.11-1.53). La presencia de enfermedades concomitantes y la edad mayor de 60 años son factores predictores de morbimortalidad en pacientes con HDA por úlcera péptica. / Trabajo de investigación

INTRODUCCIÓN: El cáncer gastrointestinal, como el gástrico y de colon, genera un deterioro de la calidad de vida porque conlleva a un estrés catabólico o caquexia; y así el paciente se expone a una alta morbimortalidad. Investigaciones refieren que la administración de dietas inmunomoduladoras en el preoperatorio provee mejores beneficios que otras dietas en el periodo postoperatorio. Estudios contradicen la relación entre recuento total de linfocitos en el periodo preoperatorio con complicación postoperatoria. OBJETIVO: Determinar la relación entre tipo de nutrición enteral y recuento total de linfocitos preoperatorios con complicación postoperatoria en pacientes con cáncer gastrointestinal. DISEÑO: Observacional, descriptivo de asociación cruzada y retrospectivo. LUGAR: Hospital Nacional Hipólito Unanue (HNHU), MINSA, Lima, Perú. INTERVENCIONES: Se revisaron historias clínicas de pacientes con diagnóstico de cáncer gastrointestinal que fueron intervenidos quirúrgicamente en el servicio de Cirugía General del Hospital Nacional Hipólito Unanue (HNHU) entre los años 2010 y junio del 2014. El instrumento utilizado fue una ficha de recolección de datos. PRINCIPALES MEDIDAS DE RESULTADOS: Relación entre tipo de nutrición enteral y recuento total de linfocitos preoperatorios con complicación postoperatoria en pacientes con cáncer gastrointestinal. RESULTADOS: 35 historias clínicas conformaron el estudio. Del total de casos el 65,7% (23 de 35) fueron pacientes con diagnóstico de cáncer gástrico; y el 34,3% (12 de 35) fueron de cáncer de colon. 16 (45,7%) pacientes fueron del sexo femenino. El promedio de edad fue de 58,6 años ± 8,2. El análisis entre el tipo de nutrición enteral preoperatoria recibida con la presencia de una complicación postoperatoria al inicio del periodo mediato dio como resultado un p=0,020. El análisis entre recuento total de linfocitos preoperatorio con la presencia de una complicación postoperatoria en la recuperación hospitalaria dio como resultado un p=0,877. CONCLUSIÓN: Una nutrición enteral con fórmula inmunomoduladora aplicada por un mínimo de 7 días previo a la cirugía en la población de estudio (n=35) se relacionó estadísticamente significativa con menor incidencia de complicaciones postoperatorias al inicio del periodo mediato. / Tesis

Tesis por compendio / [ES] Esta tesis doctoral se centró en la valorización de diferentes fuentes de biomasa marina para desarrollar materiales biopoliméricos e ingredientes destinados a la industria alimentaria. Así pues, en la primera parte de la tesis, se llevó a cabo la valorización de la biomasa de diversas especies de algas con el objetivo de identificar compuestos de interés y evaluar su potencial para la producción de materiales biopoliméricos e ingredientes alimentarios ricos en proteínas. Entre estas especies se encontraba R. okamurae, un alga parda invasora que representa una amenaza para los ecosistemas marinos. No obstante, se demostró que esta especie posee un gran potencial como fuente sostenible de compuestos bioactivos, transformando su papel de amenaza en oportunidad. La biomasa de las algas rojas también destacó por su potencial en diversas aplicaciones, incluyendo el desarrollo de materiales rentables y respetuosos con el medio ambiente obtenidos mediante de un procesado mínimo. En este contexto, la composición y la estructura de las paredes celulares de las algas desempeñaron un papel fundamental para entender cómo se comporta cada especie durante el procesado y en las propiedades de las películas resultantes. Además de la producción de materiales, también se estudiaron las algas rojas como fuente de proteínas para el consumo humano. Aunque las algas nativas presentaron una baja digestibilidad, esta mejoró mediante su procesado. No obstante, a pesar de esta mejora en la digestibilidad, el procesado podía inducir la degradación de los aminoácidos más lábiles, lo que repercutía negativamente en la calidad nutricional de las proteínas. En la segunda parte de esta tesis, se exploraron varias especies de algas rojas para extraer agar de forma más eficiente mediante métodos simplificados, y se evaluó la idoneidad de los extractos obtenidos para desarrollar materiales biopoliméricos e hidrogeles para aplicaciones alimentarias. El grado de purificación del agar tuvo un impacto significativo en las propiedades finales tanto de las películas como de los hidrogeles. En el caso de las películas, las fabricadas con agar puro presentaron propiedades superiores; sin embargo, sufrieron cambios significativos en su estructura semicristalina durante el almacenamiento. Por el contrario, las películas derivadas de extractos de agar menos purificados mostraron una mayor estabilidad en el tiempo, sugiriendo su potencial como aditivo para reducir costes y mejorar la estabilidad de las películas de agar puro. En el caso de los hidrogeles, la purificación del agar condujo a la formación de hidrogeles con una resistencia y dureza más altas. Por otro lado, el protocolo de extracción simplificado produjo fracciones de agar menos purificadas que contenían compuestos adicionales como proteínas o polifenoles. Aunque esto dio lugar a hidrogeles menos rígidos y resistentes, podrían ser de interés para la producción de hidrogeles con propiedades bioactivas. En la tercera y última parte de la tesis, se abordó la valorización de los residuos industriales generados tras la extracción de alginato, con el propósito de obtener fracciones de celulosa mediante métodos simplificados para su aplicación en la producción de materiales biopoliméricos. En este contexto, se observó que los residuos de A. esculenta y S. latissima resultaron adecuados para la extracción de fracciones celulósicas, mientras que A. nodosum podría ser más interesante para la producción de extractos ricos en fucoidano. Las fracciones de celulosa con mayor pureza generaron películas con propiedades mecánicas y aspecto visual más deseables. En cambio, las fracciones menos purificadas presentaron una mayor barrera al vapor de agua. De acuerdo con los resultados, se determinó que la simple aplicación de un tratamiento alcalino puede producir fracciones de celulosa que dan lugar a películas con un equilibrio óptimo entre propiedades funcionales y eficiencia económica y medioambiental. / [CA] Aquesta tesi doctoral es va centrar en la valorització de diferents fonts de biomassa marina para desenvolupar materials biopolimèrics i ingredients destinats a la indústria alimentària. Així doncs, en la primera part de la tesi, es va dur a terme la valorització de la biomassa de diverses espècies d'algues amb l'objectiu d'identificar compostos d'interés i avaluar el seu potencial per a la producció de materials biopolimèrics i ingredients alimentaris rics en proteïnes. Entre aquestes espècies es trobava R. okamurae, una alga marró invasora que representa una amenaça per als ecosistemes marins. No obstant això, es va demostrar que aquesta espècie posseeix un gran potencial com a font sostenible de compostos bioactius, transformant el seu paper d'amenaça en oportunitat. La biomassa de les algues roges també va destacar pel seu potencial en diverses aplicacions, incloent-hi el desenvolupament de materials rendibles i respectuosos amb el medi ambient obtinguts mitjançant d'un processament mínim. En aquest context, la composició i l'estructura de les parets cel·lulars de les algues van exercir un paper fonamental per a entendre el comportament cada espècie durant el processament i en les propietats de les pel·lícules resultants. A més, també es van estudiar les algues roges com a font de proteïnes per al consum humà. Encara que les algues natives van presentar una baixa digestibilitat, aquesta va millorar mitjançant el seu processament. No obstant això, malgrat aquesta millora en la digestibilitat, el processament podia induir la degradació dels aminoàcids més làbils, la qual cosa repercutia negativament en la qualitat nutricional de les proteïnes. En la segona part d'aquesta tesi, es van explorar diverses espècies d'algues roges per a extraure agar de forma més eficient mitjançant mètodes simplificats, i es va avaluar la idoneïtat dels extractes obtinguts per a desenvolupar materials biopolimèrics i hidrogels per a aplicacions alimentàries. El grau de purificació de l'agar va tindre un impacte significatiu en les propietats finals tant de les pel·lícules com dels hidrogels. En el cas de les pel·lícules, les fabricades amb agar pur van presentar propietats superiors; no obstant això, van patir canvis significatius en la seua estructura semicristal·lina durant l'emmagatzematge. Per contra, les pel·lícules derivades d'extractes d'agar menys purificats van mostrar una major estabilitat en el temps, suggerint el seu potencial com a additiu per a reduir costos i millorar l'estabilitat de les pel·lícules d'agar pur. En el cas dels hidrogels, la purificació de l'agar va conduir a la formació d'hidrogels amb una resistència i duresa més altes. D'altra banda, el protocol d'extracció simplificat va produir fraccions d'agar menys purificades que contenien compostos addicionals com a proteïnes o polifenols. Encara que això va donar lloc a hidrogels menys rígids i resistents, podrien ser d'interés per a la producció d'hidrogels amb propietats bioactius. En la tercera i última part de la tesi, es va abordar la valorització dels residus industrials generats després de l'extracció d'alginat, amb el propòsit d'obtindre fraccions de cel·lulosa mitjançant mètodes simplificats per a la seua aplicació en la producció de materials biopolimèrics. En aquest context, es va observar que els residus de A. esculenta i S. latissima van resultar adequats per a l'extracció de fraccions cel·lulòsiques, mentre que A. nodosum podria ser més interessant per a la producció d'extractes rics en fucoidans. Les fraccions de cel·lulosa amb major puresa van generar pel·lícules amb propietats mecàniques i aspecte visual més desitjables. En canvi , les fraccions menys purificades van presentar una major barrera al vapor d'aigua. D'acord amb els resultats, es va determinar que la simple aplicació d'un tractament alcalí pot produir fraccions de cel·lulosa que donen lloc a pel·lícules amb un equilibri òptim entre propietats funcionals i eficiència econòmica i mediambiental. / [EN] This doctoral thesis focused on the valorization of different sources of marine biomass with the main purpose of developing biopolymeric materials and ingredients for the food industry. Thus, in the first part of the thesis, the valorization of biomass from different algae species was carried out to identify compounds of interest and assess their potential to produce biopolymeric materials and protein-rich food ingredients. Among these species was Ruguloperyx okamurae, an invasive brown seaweed that poses a threat to marine ecosystems. However, this species was shown to have significant potential as a sustainable source of bioactive compounds, transforming its role as a threat into a valuable opportunity. Red seaweed biomass was also highlighted for its potential in a variety of applications, including the development of cost-effective and environmentally friendly materials for food applications obtained through minimal processing. In this context, the composition and structure of the algal cell walls played a crucial role in understanding how each species behaves during processing and in the properties of the resulting films. In addition to the production of biopolymeric materials, red seaweeds were also studied as a source of proteins for human consumption. Although native seaweeds had low digestibility, this was improved through processing. However, it is important to note that, despite the improvement in digestibility, processing could induce the degradation of more labile amino acids, having a negative impact on the nutritional quality of the proteins. In the second part of this thesis, several species of red seaweeds were explored to extract agar more efficiently by simplified methods, and the suitability of the extracts obtained to develop biopolymeric materials and hydrogels for food applications was evaluated. It could be observed that the degree of agar purification had a significant impact on the final properties of both films and hydrogels. In the case of films, those made of pure agar exhibited superior properties; however, they underwent significant changes in their semicrystalline structure during storage. In contrast, those films derived from less purified agar extracts showed greater stability over time, suggesting the potential of less purified agars as additives to reduce costs and improve the stability of pure agar films. Regarding the hydrogels, agar purification led to the formation of hydrogels with significantly higher strength and hardness. On the other hand, the simplified extraction protocol produced less purified agar fractions containing other compounds such as proteins, polyphenols, and minerals. Although this resulted in less rigid and resistant hydrogels, this feature could be advantageous for the production of hydrogels with bioactive properties. In the third and last part of the thesis, the valorization of industrial wastes generated after alginate extraction was addressed, with the purpose of obtaining cellulosic fractions by simplified methods for their application in the production of biopolymeric materials. In this context, it was observed that the residues of Alaria esculenta and Saccharina latissima were suitable for the extraction of cellulosic fractions, while Ascophyllum nodosum might be more interesting for the production of fucoidan-rich extracts. Cellulosic fractions with higher purity produced films with more desirable mechanical properties and visual appearance. Conversely, less purified fractions presented a greater barrier to water vapor. According to the results, it was determined that the simple application of an alkaline treatment could produce cellulosic fractions that resulted in films with an optimal balance between functional properties and economic and environmental efficiency in biopolymeric material production. / This work was financially supported by the “Agencia Estatal de Investigación” (PCI2018-092886 Grant) and co-funded by the European Union’s Horizon 2020 research and innovation programme (ERA-Net SUSFOOD2) and by the grant TED2021-129711B-I00, funded by MCIN/AEI/10.13039/501100011033 and by the European Union NextGenerationEU/PRTR. This work was done within the framework of a collaboration with HISPANAGAR S.L (Burgos, Spain). The research was funded by the Spanish Ministry of Science, Innovation and Universities through projects PID2020-114821RB-I00, PID2020-117744RJ-I00, as well as CEX2021-001189-S, funded by MCIN/AEI/10.13039/501100011033. The authors also acknowledge funding through project CIRCALGAE (Horizon Europe) under grant agreement 101060607. In all projects, funding from “ERDF A way of making Europe”, the “European Union” or the “European Union NextGenerationEU/PRTR” is also acknowledged. / Cebrián Lloret, V. (2024). Valorization of Marine Biomass for the Development of Biopolymeric Materials and Additives with Functional Properties [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/202961 / Compendio

O Glutarldeído é usado como desinfetante de endoscópios, mas por ser irritante, deve ser substituído por outro produto alternativo. A água ácida eletrolisada (AAE) possui efeito bactericida, tecnologia essa desenvolvida no Japão para lavadoras de endoscópios. No nosso estudo, a contaminação endoscópica após o seu uso clínico foi examinada através de cultura para bactérias, micobactérias e fungos, tanto antes quanto após a desinfecção com glutaraldeído por 20 minutos ou água ácida eletrolizada por 7 minutos. As colônias de bactérias foram identificadas e contadas após 48 horas de incubação a 37o C. A contaminação microbiana dos colonoscópios foi detectada após 30 (trinta) procedimentos endoscópicos, contudo o tratamento com a AAE conseguiu erradicar todos os microorganismos. A atividade microbiana da AAE mostrou-se ser similar ao glutaraldeído a 2%. Os resultados indicam que a AAE é um eficiente desinfetante depois da limpeza mecânica dos colonoscópios, podendo ser usado nas unidades de endoscopias como uma alternativa ao glutaraldeído / Efficient disinfection is important given the multiplicity of bacterial exposures to equipment used in endoscopy. Glutaraldehyde is used as a disinfectant for endoscopes, but is an irritant and so should be replaced by an alternative. Electrolized cid water (EAW) has bactericidal effect, and an endoscopic washing device using EAW has been developed in Japan. In our study, endoscopic contamination after clinical use was examinated by culture for bacteria, mycobacteria and fungi before and after exposing to glutaraldehyde (20min) and electrolized acid water (7min). The bacterial colonies were identified and counted after 48 hours of incubation at 37oC. Microbial contamination of colonoscopes was detected after 30 endoscopic procedures, but the treatment of the endoscope with EAW eradicated the microbes. The microbicidal activities of EAW was similar to that of glutaraldehyde. These results indicate that EAW is effective disinfectant after mechanical cleaning of colonoscopes, and can, therefore, be used in the endoscopy unit as an alternative to glutaraldehyde

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Nowadays there are no more discussions related to the efficience use of sorghum in feed of broilers as well as anatomo-physiological changes triggered by the larger particle size of the ration particle. The success of the combination of these factors can lead to great economic advantage in the modern poultry industry. In this sense, three experiments were carried out in order to evaluate the effect of whole grain sorghum compared to maize and milled sorghum on the gastrointestinal tract and on carcass characteristics of broilers at 7 and 42 day old. The whole sorghum grain: (1) In broilers at 7 and 42 day old it provides greater body weight, due to its higher digestibility and increased gizzard weight by exercising greater mechanical work because of the larger particle size; (2) It increases duodenal crypt depth at 7 and 42 day old and jejunum at 42 day old without, however, affecting the characteristic of the villi of the small intestine and absorption surface area of intestinal mucosa in both evaluated age, (3) It does not affect the relative weight and length of the intestine, (4) It can replace corn without harming the commercial cuts yield as well as the chemical characteristics of the carcass; (5) It increases the visceral content and it is not advantageous for the carcass yield; for this purpose it is recommended to use the milled grain sorghum; (6) It excludes costs with grinding reducing the production cost of poultry. / Nos dias atuais já não se discute a eficiência da utilização do sorgo na alimentação de frangos de corte, bem como as alterações anato-fisiológicas desencadeadas pelo maior tamanho de partícula da ração. O êxito da combinação destes fatores pode gerar grande vantagem econômica na avicultura moderna. Neste sentido, foram realizados três experimentos com o objetivo de avaliar o efeito do sorgo grão inteiros em comparação ao milho e ao sorgo moído sobre o trato gastrintestinal e sobre as características de carcaça de frangos de corte aos 7 e aos 42 dias de idade. O sorgo grão inteiro: (1) Em frangos de corte aos 7 e 42 dias de idade proporciona maior peso corporal por apresentar maior digestibilidade e maior peso da moela por exercer maior trabalho mecânico devido o maior tamanho de partícula; (2) Aumenta a profundidade de cripta do duodeno aos 7 e 42 dias e do jejuno aos 42 dias de idade, sem contudo, afetar a característica das vilosidades do intestino delgado e a área de superfície de absorção da mucosa intestinal nas duas idades avaliadas; (3) Não afeta o peso e o comprimento relativo do intestino; (4) Pode substituir o milho sem prejudicar o rendimento de cortes comerciais bem como as características químicas da carcaça; (5) Aumenta a o conteúdo visceral e não é vantajoso para o rendimento de carcaça, para este fim recomenda-se a utilização do sorgo grão moído; (6) Exclui custos com moagem diminuindo o custo de produção do frango. / Mestre em Ciências Veterinárias

O Glutarldeído é usado como desinfetante de endoscópios, mas por ser irritante, deve ser substituído por outro produto alternativo. A água ácida eletrolisada (AAE) possui efeito bactericida, tecnologia essa desenvolvida no Japão para lavadoras de endoscópios. No nosso estudo, a contaminação endoscópica após o seu uso clínico foi examinada através de cultura para bactérias, micobactérias e fungos, tanto antes quanto após a desinfecção com glutaraldeído por 20 minutos ou água ácida eletrolizada por 7 minutos. As colônias de bactérias foram identificadas e contadas após 48 horas de incubação a 37o C. A contaminação microbiana dos colonoscópios foi detectada após 30 (trinta) procedimentos endoscópicos, contudo o tratamento com a AAE conseguiu erradicar todos os microorganismos. A atividade microbiana da AAE mostrou-se ser similar ao glutaraldeído a 2%. Os resultados indicam que a AAE é um eficiente desinfetante depois da limpeza mecânica dos colonoscópios, podendo ser usado nas unidades de endoscopias como uma alternativa ao glutaraldeído / Efficient disinfection is important given the multiplicity of bacterial exposures to equipment used in endoscopy. Glutaraldehyde is used as a disinfectant for endoscopes, but is an irritant and so should be replaced by an alternative. Electrolized cid water (EAW) has bactericidal effect, and an endoscopic washing device using EAW has been developed in Japan. In our study, endoscopic contamination after clinical use was examinated by culture for bacteria, mycobacteria and fungi before and after exposing to glutaraldehyde (20min) and electrolized acid water (7min). The bacterial colonies were identified and counted after 48 hours of incubation at 37oC. Microbial contamination of colonoscopes was detected after 30 endoscopic procedures, but the treatment of the endoscope with EAW eradicated the microbes. The microbicidal activities of EAW was similar to that of glutaraldehyde. These results indicate that EAW is effective disinfectant after mechanical cleaning of colonoscopes, and can, therefore, be used in the endoscopy unit as an alternative to glutaraldehyde