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Introduction and objectivesNephrolithiasis has a multifactorial etiology, wherein, besides metabolic factors, the anatomy of the pelvicalyceal system might play a role. Using 3D-reconstructions of CT-urography (CT-U), we studied the morphometric properties of pelvicalyceal anatomy affecting kidney stone formation and compared those with existing literature on their effect on minimally invasive treatment techniques for renal calculi.MethodsCT-U’s were made between 01-01-2017 and 30-09-2018. Patients were chronologically included in two groups: a nephrolithiasis group when ≥ 1 calculus was present on the CT-U and a control group of patients with both the absence of calculi on the CT-U and no medical history of urolithiasis. Patients with a medical history of diseases leading to higher risks on urolithiasis were excluded. In the nephrolithiasis group affected kidneys were measured. In the control group, left and right kidneys were alternately measured.ResultsTwenty kidneys were measured in both groups. Mean calyceopelvic tract width was significantly larger in the lower segments of affected kidneys (3.9 vs. 2.7 mm). No significant differences between the groups were found in number of calyces, infundibular length, infundibular width, calyceopelvic angle, upper–lower angle and diameters of the pelvis. Transversal calyceal orientation in hours was significantly smaller in the upper and lower segments of the nephrolithiasis group (7.69 vs. 8.52 and 8.08 vs. 9.09 h), corresponding with more dorsally located calyces in stone-forming kidneys.ConclusionPelvicalyceal anatomy differs between stone-forming and non-stone-forming kidneys. Understanding the pelvicalyceal system and etiology of stone formation can improve development of endourological techniques.

Samenvatting Er is onvoldoende bekend over de middellangetermijnoverleving van niet-gemetastaseerd spierinvasieve blaaskanker (SIBC) na open (ORC) versus robotgeassisteerde (RARC) cystectomie, met of zonder neoadjuvante chemotherapie (NAC). Om de vijfjaarsoverleving na beide interventies en de invloed van NAC te onderzoeken, is een retrospectieve studie verricht in 19 Nederlandse ziekenhuizen tussen 2012 en 2015. Van de totaal 1.534 cT1-4N0-1-patiënten ondergingen 1.086 patiënten een ORC en 389 een RARC. De vijfjaarsoverleving was 51% na ORC (95%-BI 47–53) versus 58% na RARC (95%-BI 52–63); de hazard ratio na multivariabele correctie was 1,00 (95%-BI 0,84–1,20). 226 van de 965 cT2-4aN0-patiënten werden behandeld met NAC. Na case-control matching bleek (y)pT0 vaker voor te komen na NAC dan zonder NAC (31 vs. 15%; p  < 0,01). De beste vijfjaarsoverleving trad op bij patiënten met ypT0 na NAC, namelijk 89% (95%-BI 81–97). Concluderend laat deze deze studie bij patiënten met SIBC vergelijkbare vijfjaarsoverleving zien na ORC of na RARC. De beste overleving was bij patiënten die waren behandeld met NAC voorafgaand aan cystectomie.

Samenvatting Een terugkerend urologisch dilemma is of bij mannen een cystolithotripsie gecombineerd moet worden met een transurethrale resectie van de prostaat (TURP), om een blaassteenrecidief te voorkomen en steenlozing te faciliteren. Er zijn aanwijzingen dat ook zonder gelijktijdige TURP het percentage recidieven klein is. In dit retrospectieve multicenteronderzoek is nagegaan wat de waarde is van een TURP in deze context. In totaal werden in vijf centra 127 patiënten geïncludeerd. TURP ten tijde van de cystolithotripsie lijkt een bescheiden beschermend effect te hebben op de middellange termijn (NNT = 7). Van de patiënten die niet gelijktijdig een TURP ondergingen, bleef 81 % op middellange termijn vrij van een recidief. Wat ons betreft geldt gezamenlijke besluitvorming als het nieuwe adagium bij mannen met blaasstenen.

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5–7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.

General practitioners (GPs) often assess patients with acute infections. It is challenging for GPs to recognize patients needing immediate hospital referral for sepsis while avoiding unnecessary referrals. This study aimed to predict adverse sepsis-related outcomes from telephone triage information of patients presenting to out-of-hours GP cooperatives. A retrospective cohort study using linked routine care databases from out-of-hours GP cooperatives, general practices, hospitals and mortality registration. We included adult patients with complaints possibly related to an acute infection, who were assessed (clinic consultation or home visit) by a GP from a GP cooperative between 2017-2019. We used telephone triage information to derive a risk prediction model for sepsis-related adverse outcome (infection-related ICU admission within seven days or infection-related death within 30 days) using logistic regression, random forest, and neural network machine learning techniques. Data from 2017 and 2018 were used for derivation and from 2019 for validation. We included 155,486 patients (median age of 51 years; 59% females) in the analyses. The strongest predictors for sepsis-related adverse outcome were age, type of contact (home visit or clinic consultation), patients considered ABCD unstable during triage, and the entry complaints\"general malaise\", \"shortness of breath\" and \"fever\". The multivariable logistic regression model resulted in a C-statistic of 0.89 (95% CI 0.88-0.90) with good calibration. Machine learning models performed similarly to the logistic regression model. A \"sepsis alert\" based on a predicted probability >1% resulted in a sensitivity of 82% and a positive predictive value of 4.5%. However, most events occurred in patients receiving home visits, and model performance was substantially worse in this subgroup (C-statistic 0.70). Several patient characteristics identified during telephone triage of patients presenting to out-of-hours GP cooperatives were associated with sepsis-related adverse outcomes. Still, on a patient level, predictions were not sufficiently accurate for clinical purposes.

Purpose The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years. Methods Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0–4). Potential studies were ranked on the basis of average score. Results Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies. Conclusions Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity.

Metabolic alterations in the critically ill have been studied for more than a century, but the heterogeneity of the critically ill patient population, the varying duration and severity of the acute phase of illness, and the many confounding factors have hindered progress in the field. These factors may explain why management of metabolic alterations and related conditions in critically ill patients has for many years been guided by recommendations based essentially on expert opinion. Over the last decade, a number of randomized controlled trials have been conducted, providing us with important population-level evidence that refutes several longstanding paradigms. However, between-patient variation means there is still substantial uncertainty when translating population-level evidence to individuals. A cornerstone of metabolic care is nutrition, for which there is a multifold of published guidelines that agree on many issues but disagree on others. Using a series of nine questions, we provide a review of the latest data in this field and a background to promote efforts to address the need for international consistency in recommendations related to the metabolic care of the critically ill patient. Our purpose is not to replace existing guidelines, but to comment on differences and add perspective.

PurposeFeed production is responsible for the majority of the environmental impact of livestock production, especially for monogastric animals, such as pigs. Some feeding strategies demonstrated that replacing one ingredient with a high impact, e.g. soybean meal (SBM), with an alternative protein source, e.g. locally produced peas or rapeseed meal, has potential to reduce the environmental impact. These studies, however, used an attributional life cycle assessment (ALCA), which solely addresses the direct environmental impact of a product. A replacement of SBM with alternative protein sources, however, can also have indirect environmental consequences, which might change environmental benefits of using alternative protein sources. This study aims to explore differences in results when performing an ALCA and a CLCA to reduce the environmental impact of pig production. We illustrated this for two case studies: replacing SBM with rapeseed meal (RSM), and replacing SBM with waste-fed larvae meal in diets of finishing-pigs.MethodsWe used an ALCA and CLCA to assess global warming potential (GWP), energy use (EU) and land use (LU) of replacing SBM with RSM and waste-fed larvae meal, for finishing-pigs. The functional unit was 1 kg of body weight gain.Results and discussionBased on an ALCA, replacing SBM with RSM showed that GWP (3%) and EU (1%) were not changed, but LU was decreased (14%). ALCA results for replacing SBM with waste-fed larvae meal showed that EU did not change (1%), but GWP (10%) and LU (56%) were decreased. Based on a CLCA, replacing SBM with RSM showed an increased GWP (15%), EU (12%) and LU (10%). Replacing SBM with waste-fed larvae meal showed an increased GWP (60%) and EU (89%), but LU (70%) was decreased. Furthermore, the results of the sensitivity analysis showed that assumptions required to perform a CLCA, such as definition of the marginal product, have a large impact on final results but did not affect the final conclusions.ConclusionsThe CLCA results seem to contradict the ALCA results. CLCA results for both case studies showed that using co-products and waste-fed larvae meal currently not reduces the net environmental impact of pork production. This would have been overlooked when results were only based on ALCA. To gain insight into the environmental impact of feed, animal nutritionists can use an ALCA. If policy makers or the feed industry, however, want to assess the net environmental impact of a potential feeding strategy, it is recommended to perform a CLCA. Feed and food markets are, however, highly dynamic. Pig feed optimization is based on least cost optimization and a wide range of ingredients are available; diet compositions can, therefore, change easily, resulting in different environmental impacts. Ideally, therefore, a CLCA should include a sensitivity analysis (e.g. different feed prices or different marginal products) to provide a range of possible outcomes to make the results more robust.

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.