Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

BACKGROUND: Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. METHODS/DESIGN: The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. DISCUSSION: The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

BACKGROUND: Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. METHODS: In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099. FINDINGS: After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04). INTERPRETATION: In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. FUNDING: La Roche-sur-Yon Departmental Hospital and French Ministry of Health

Paludicola

Since the first phylogenetic study of the order Batrachospermales, Batrachospermum was shown to be paraphyletic. Subsequently, sections of the genus have been methodically investigated using DNA sequences and morphology in order to propose new genera and delineate species. Batrachospermum section Turfosa is the last section with multiple species yet to be examined. New sequence data of specimens from Europe and the United States were combined with the sparse sequence data already available. Phylogenetic analyses using rbcL and COI-5P sequences showed this section to be a well-supported clade, distinct from Batrachospermum section Batrachospermum and its segregate genera. Section Turfosa is raised to the generic rank as Paludicola gen. nov. Substantial genetic variation within the genus was discovered and 12 species are recognized based on DNA sequence data as well as morphological characters and geographic distribution. The following morphological characters were applied to distinguish species: branching pattern (pseudodichotomous or irregular), whorl size (reduced or well developed), primary fascicles (curved or straight), spermatangia origin (primary or secondary fascicles), and carposporophyte arrangement (loose or dense). Previously published species were transferred to the new genus: P. turfosa, P. keratophyta, P. orthosticha, P. phangiae, and P. periploca. Seven new species are proposed as follows: P. groenbladii from Europe; P. communis, P. johnhallii, and P. leafensis from North America; and P. aquanigra, P. diamantinensis, and P. turfosiformis from Brazil. In addition, three unsequenced species in the section, P. bakarensis, P. gombakensis, and P. tapirensis, were transferred to the new genus.NSFFundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Polish Ministry of Sciences and Higher Education grantOhio Univ, Dept Environm & Plant Biol, Athens, OH 45701 USAPAS, Dept Freshwater Biol, Inst Nat Conservat, Al A Mickiewicza 33, PL-31120 Krakow, PolandSinkilatie 13, FI-40530 Jyvaskyla, FinlandGranada Univ, Dept Bot, Granada 18071, SpainUniv Alabama, Dept Biol Sci, Tuscaloosa, AL 35487 USASao Paulo State Univ, Dept Bot & Zool, Rua Cristovao Colombo 2265, BR-15054000 Sao Jose Do Rio Preto, BrazilSao Paulo State Univ, Dept Bot & Zool, Rua Cristovao Colombo 2265, BR-15054000 Sao Jose Do Rio Preto, BrazilNSF: DEB0936855NSF: DEB1655230FAPESP: 12/12016-6FAPESP: 16/07808-1Polish Ministry of Sciences and Higher Education grant: N N304 28593

Systematics of the section Virescentia

This study evaluated the species level taxonomy and phylogenetic relationships among species of the section Virescentia of the genus Batrachospermum focusing on specimens from Brazil and other regions of the world. Molecular data (sequences of the plastid-encoded RuBisCO large-subunit gene, rbcL; and the barcode region of the mitochondrial encoded cytochrome c oxidase subunit 1, cox1) were generated, and morphological characters described for 13 populations. Molecular analyses of rbcL sequences revealed the existence of three well-supported clades with evident biogeographic trends, containing sequences of specimens of either North America (USA), Asia (Japan) or Brazil. Similarly, analysis of cox1 sequences (slightly different taxon sampling) also revealed three clades, containing specimens of either North America (USA), Europe (Norway) or Brazil. The three species recognized from Brazil in a previous study based on morphological data (Batrachospermum helminthosum, B. sirodotii and B. vogesiacum) could not be distinguished by molecular or morphological data. A new species was proposed for Brazilian specimens based on molecular and morphological evidence. Batrachospermum viride-brasiliense differed from the European species of the section Virescentia (B. bruziense, B. coerulescens, B. elegans, B. sirodotii and B. vogesiacum) by the longer carpogonia ( 40 lm) and larger carposporophytes ( 200 lm in diameter and 100 lm high) and carposporangia ( 19 lm long and 10 lm in diameter).Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Estadual Paulista Júlio de Mesquita Filho, Instituto de Biociências Letras e Ciências Exatas de São José do Rio Preto, São José do Rio Preto, Rua Cristóvão Colombo, 2265, Jardim Nazareth, CEP 15054000, SP, BrasilUniversidade Estadual Paulista Júlio de Mesquita Filho, Departamento de Zoologia e Botânica, Instituto de Biociências Letras e Ciências Exatas de São José do Rio PretoCNPq 507228/2010-3CNPq 487566/2012-2FAPESP 2007/51270-7FAPESP 2008/00708-

Severe leptospirosis in non-tropical areas: a nationwide, multicentre, retrospective study in French ICUs

International audiencePurpose: To report the incidence, risk factors, clinical presentation, and outcome predictors of severe leptospirosis requiring intensive care unit (ICU) admission in a temperate zone.Methods: LEPTOREA was a retrospective multicentre study conducted in 79 ICUs in metropolitan France. Consecutive adults admitted to the ICU for proven severe leptospirosis from January 2012 to September 2016 were included. Multiple correspondence analysis (MCA) and hierarchical classification on principal components (HCPC) were performed to distinguish different clinical phenotypes.Results: The 160 included patients (0.04% of all ICU admissions) had median values of 54 years [38-65] for age, 40 [28-58] for the SAPSII, and 11 [8-14] for the SOFA score. Hospital mortality was 9% and was associated with older age; worse SOFA score and early need for endotracheal ventilation and/or renal replacement therapy; chronic alcohol abuse and worse hepatic dysfunction; confusion; and higher leucocyte count. Four phenotypes were identified: moderately severe leptospirosis (n = 34, 21%) with less organ failure and better outcomes; hepato-renal leptospirosis (n = 101, 63%) with prominent liver and kidney dysfunction; neurological leptospirosis (n = 8, 5%) with the most severe organ failures and highest mortality; and respiratory leptospirosis (n = 17, 11%) with pulmonary haemorrhage. The main risk factors for leptospirosis contamination were contact with animals, contact with river or lake water, and specific occupations.Conclusions: Severe leptospirosis was an uncommon reason for ICU admission in metropolitan France and carried a lower mortality rate than expected based on the high severity and organ-failure scores. The identification in our population of several clinical presentations may help clinicians establish an appropriate index of suspicion for severe leptospirosis