First Citizen Peace, ho! I do entreat you, not a man depart, Save I alone, till Antony have spoke. Exit First Citizen Stay, ho! Noble Antony, go up. Goes into the pulpit Fourth Citizen What does he say of Brutus? Fourth Citizen Twere best he speak no harm of Brutus here. First Citizen This Caesar was a tyrant. Second Citizen Peace! The evil that men do lives after them; The good is oft interred with their bones; So let it be with Caesar. He was my friend, faithful and just to me: But Brutus says he was ambitious; And Brutus is an honourable man.
He hath brought many captives home to Rome Whose ransoms did the general coffers fill: Did this in Caesar seem ambitious? When that the poor have cried, Caesar hath wept: Ambition should be made of sterner stuff: Yet Brutus says he was ambitious; And Brutus is an honourable man.
You all did see that on the Lupercal I thrice presented him a kingly crown, Which he did thrice refuse: was this ambition? Yet Brutus says he was ambitious; And, sure, he is an honourable man. I speak not to disprove what Brutus spoke, But here I am to speak what I do know.
You all did love him once, not without cause: What cause withholds you then, to mourn for him? O judgment! Bear with me; My heart is in the coffin there with Caesar, And I must pause till it come back to me. First Citizen Methinks there is much reason in his sayings.
Second Citizen If thou consider rightly of the matter, Caesar has had great wrong. Third Citizen Has he, masters? I fear there will a worse come in his place.
First Citizen If it be found so, some will dear abide it. Second Citizen Poor soul! Fourth Citizen Now mark him, he begins again to speak. And none so poor to do him reverence. O masters, if I were disposed to stir Your hearts and minds to mutiny and rage, I should do Brutus wrong, and Cassius wrong, Who, you all know, are honourable men: I will not do them wrong; I rather choose To wrong the dead, to wrong myself and you, Than I will wrong such honourable men.
All The will, the will! You are not wood, you are not stones, but men; And, being men, bearing the will of Caesar, It will inflame you, it will make you mad: Tis good you know not that you are his heirs; For, if you should, O, what would come of it! Fourth Citizen They were traitors: honourable men! All The will! Second Citizen They were villains, murderers: the will! Then make a ring about the corpse of Caesar, And let me show you him that made the will.
Shall I descend? Several Citizens Come down. Second Citizen Descend. Third Citizen You shall have leave. First Citizen Stand from the hearse, stand from the body. Second Citizen Room for Antony, most noble Antony. Several Citizens Stand back; room; bear back. O, what a fall was there, my countrymen! O, now you weep; and, I perceive, you feel The dint of pity: these are gracious drops.
First Citizen O piteous spectacle! Second Citizen O noble Caesar! Third Citizen O woful day! Fourth Citizen O traitors, villains! First Citizen O most bloody sight! Second Citizen We will be revenged. All Revenge! Let not a traitor live! First Citizen Peace there! They that have done this deed are honourable: What private griefs they have, alas, I know not, That made them do it: they are wise and honourable, And will, no doubt, with reasons answer you.
Third Citizen Away, then! All Peace, ho! Hear Antony. Most noble Antony! Alas, you know not: I must tell you then: You have forgot the will I told you of. All Most true. The will! To every Roman citizen he gives, To every several man, seventy-five drachmas. Second Citizen Most noble Caesar! Third Citizen O royal Caesar! ANTONY Moreover, he hath left you all his walks, His private arbours and new-planted orchards, On this side Tiber; he hath left them you, And to your heirs for ever, common pleasures, To walk abroad, and recreate yourselves.
Here was a Caesar! First Citizen Never, never. Come, away, away! Take up the body. Second Citizen Go fetch fire. Third Citizen Pluck down benches. Fourth Citizen Pluck down forms, windows, any thing. Mischief, thou art afoot, Take thou what course thou wilt! Enter a Servant How now, fellow! Servant Sir, Octavius is already come to Rome. Fortune is merry, And in this mood will give us any thing. Bring me to Octavius.
Enter Citizens First Citizen What is your name? Second Citizen Whither are you going? Third Citizen Where do you dwell? Fourth Citizen Are you a married man or a bachelor? Second Citizen Answer every man directly. First Citizen Ay, and briefly. Fourth Citizen Ay, and wisely. Third Citizen Ay, and truly, you were best. Whither am I going? Where do I dwell?
Am I a married man or a bachelor? Then, to answer every man directly and briefly, wisely and truly: wisely I say, I am a bachelor. Proceed; directly. First Citizen As a friend or an enemy? Second Citizen That matter is answered directly. Fourth Citizen For your dwelling,—briefly. Third Citizen Your name, sir, truly. Fourth Citizen Tear him for his bad verses, tear him for his bad verses. Third Citizen Tear him, tear him!
Come, brands ho! ANTONY Octavius, I have seen more days than you: And though we lay these honours on this man, To ease ourselves of divers slanderous loads, He shall but bear them as the ass bears gold, To groan and sweat under the business, Either led or driven, as we point the way; And having brought our treasure where we will, Then take we down his load, and turn him off, Like to the empty ass, to shake his ears, And graze in commons.
Your master, Pindarus, In his own change, or by ill officers, Hath given me some worthy cause to wish Things done, undone: but, if he be at hand, I shall be satisfied. A word, Lucilius; How he received you, let me be resolved. There are no tricks in plain and simple faith; But hollow men, like horses hot at hand, Make gallant show and promise of their mettle; But when they should endure the bloody spur, They fall their crests, and, like deceitful jades, Sink in the trial. Comes his army on?
Low march within March gently on to meet him. Speak the word along. First Soldier Stand! Second Soldier Stand! Third Soldier Stand! And, if not so, how should I wrong a brother? Speak your griefs softly: I do know you well. Before the eyes of both our armies here, Which should perceive nothing but love from us, Let us not wrangle: bid them move away; Then in my tent, Cassius, enlarge your griefs, And I will give you audience.
Let Lucius and Titinius guard our door. You know that you are Brutus that speak this, Or, by the gods, this speech were else your last. What, shall one of us That struck the foremost man of all this world But for supporting robbers, shall we now Contaminate our fingers with base bribes, And sell the mighty space of our large honours For so much trash as may be grasped thus?
I had rather be a dog, and bay the moon, Than such a Roman. Must I give way and room to your rash choler? Shall I be frighted when a madman stares? Must I budge? Must I observe you? BRUTUS You say you are a better soldier: Let it appear so; make your vaunting true, And it shall please me well: for mine own part, I shall be glad to learn of noble men. I did send to you For certain sums of gold, which you denied me: For I can raise no money by vile means: By heaven, I had rather coin my heart, And drop my blood for drachmas, than to wring From the hard hands of peasants their vile trash By any indirection: I did send To you for gold to pay my legions, Which you denied me: was that done like Cassius?
When Marcus Brutus grows so covetous, To lock such rascal counters from his friends, Be ready, gods, with all your thunderbolts; Dash him to pieces! You need to find the balance of the calories in your food and the calories that you burn through exercise and your body metabolism.
The more calories you burn, the more functionality you can do, which can result to weight loss for better body proportions and reduction of total body mass. They are both downloadable so you can use them anytime and anywhere for their specific purposes. Fast Food Calorie Chart Template fastfoodmarketing. However, there are empty calories that can fill us up but cannot provide the necessary nutrition that our body needs. SlideShare uses cookies to improve functionality and performance, and to provide you with relevant advertising.
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Related Books Free with a 30 day trial from Scribd. Related Audiobooks Free with a 30 day trial from Scribd. Isha Mehta. Sraddha Prajapati. Rukayat Oseni. Monika Puroshotam. Rohit Rathwa. Sayandeb Mukherjee. Hridhin KP. Abdullahi Nasiru Mohammed. Geetha Vani. Hemalatha Bokam. Show More. Recently, propranolol treatment for 1-year postburn was shown to improve peripheral lean body mass accumulation [ 28 ].
Oxandrolone, a synthetic androgen, has been shown to blunt hypermetabolism, improve bone mineral content and density, and increase the accretion of lean body mass in children with severe burn [ 29 — 32 ]. Recombinant human growth hormone rHGH has been found to reduce hypermetabolism and improve lean body mass accretion after burn, but its use has been limited because of two multicenter trials showing that growth hormone therapy increased mortality in critically ill adults [ 33 — 35 ].
More research is needed regarding the efficacy and safety of rHGH use in burn patients. Time to treatment, including time to nutrition, is an important factor for patient outcome after severe burn.
Substantial intestinal mucosal damage and increased bacterial translocation occur after burn and result in decreased absorption of nutrients [ 36 ]. Because of this, nutritional support should ideally be initiated within 24 h of injury via an enteral route [ 2 , 19 ].
In animal models, early enteral feeding has been shown to significantly attenuate the hypermetabolic response after severe burn. Mochizuki et al. This improvement of the hypermetabolic response has not borne out in human studies; however, early enteral nutrition EN has been shown to decrease circulating catecholamines, cortisol, and glucagon and preserve intestinal mucosal integrity, motility, and blood flow [ 18 , 37 — 40 ].
Early enteral feeding in humans has also shown to result in improved muscle mass maintenance, improved wound healing, decreased risk of Curling ulcer formation, and shorter intensive care unit stay [ 21 , 22 ]. Nutrition, both parenteral and enteral, is almost always administered in a continuous fashion. For parenteral nutrition PN , this is done for logistical reasons, but reasons for continuous feeding are less clear for EN.
At the start, enteral feeding is initiated in a continuous and low volume manner with slow titration to the goal volume to insure that the patient can tolerate this regimen. A continuous schedule is usually continued even when the patient is having no issues with tolerance. Continuous enteral feeding is likely a holdover from parenteral schedules and no data have shown the superiority of either schedule, but the data are limited [ 41 ].
Normal physiology functions with intermittent feeding usually during daytime hours, and further research is needed to determine if there might be a benefit to intermittent feeding after burn. The primary goal of nutritional support in burn patients is to fulfill the increased caloric requirements caused by the hypermetabolic state while avoiding overfeeding.
Numerous formulas to estimate the caloric needs of burn victims have been developed and used throughout the years [ 42 ]. One of the earliest examples is the Curreri formula [ 43 ].
The Curreri formula and many other older formulas overestimate current metabolic requirements, and more sophisticated formulas with different variables have been proposed Table 1 [ 44 ]. One study of 46 different formulas for predicting caloric needs in burn patients found that none of them correlated well with the measured energy expenditure in 24 patients [ 1 ].
Energy expenditure does fluctuate after burn, and fixed formulas often lead to underfeeding during periods of highest energy utilization and to overfeeding late in the treatment course. Indirect calorimetry IC is the current gold standard for the measurement of energy expenditure, but it is not practical to perform on a routine basis.
IC machines measure the volume of expired gas and the inhaled and exhaled concentrations of oxygen and carbon dioxide via tight-fitting face masks or ventilators, allowing for the calculation of oxygen consumption VO 2 and carbon dioxide production VCO 2 , and therefore metabolic rate [ 45 ].
The normal metabolism of mixed substrates yields an RQ of around 0. This explains one feared complication of overfeeding: difficultly weaning from ventilatory support [ 46 ]. Despite this concern, one study found that high-carbohydrate diets in a group of pediatric burn patients led to decreased muscle wasting and did not result in RQs over 1. The metabolic process involves the creation and degradation of many products necessary for biological processes.
Metabolism of three macronutrients—carbohydrates, proteins, and lipids—provide energy via different pathways Fig. Carbohydrates are the favored energy source for burn patients as high-carbohydrate diets promote wound healing and impart a protein-sparing effect. A randomized study of 14 severely burned children found that those receiving a high-carbohydrate diet in comparison to a high-fat diet had significantly less muscle protein degradation [ 48 ].
This rate can be less than the caloric amount needed to prevent lean body mass loss, meaning severely burned patients may have greater glucose needs than can be safely given. If glucose is given in excess of what can be utilized, it leads to hyperglycemia, the conversion of glucose to fat, glucosuria, dehydration, and respiratory problems [ 51 ].
The hormonal environment of stress and acute injury causes some level of insulin resistance, and many patients benefit from supplemental insulin to maintain satisfactory blood sugars. Insulin therapy also promotes muscle protein synthesis and wound healing [ 52 ]. Studies have found that severely burned patients who received insulin infusions, in conjunction with a high-carbohydrate, high-protein diet, have improved donor site healing, lean body mass, bone mineral density, and decreased length of stay [ 53 , 54 ].
Hypoglycemia is a serious side effect of insulin therapy, and patients must be monitored closely to avoid this complication. Fat is a required nutrient to prevent essential fatty acid deficiency, but it is recommended only in limited amounts [ 13 ].
After burn, lipolysis is suppressed and the utilization of lipids for energy is decreased. Additionally, multiple studies suggest that increased fat intake adversely affects immune function [ 55 , 56 ]. In addition to the amount of fat, the composition of administered fat must be considered. The most commonly used formulas contain omega-6 fatty acids such as linoleic acid, which are processed via the synthesis of arachidonic acid, a precursor of proinflammatory cytokines e.
Lipids that contain a high percentage of omega-3 fatty acids are metabolized without promoting proinflammatory molecules and have been linked to enhanced immune response, reduced hyperglycemia, and improved outcomes [ 57 , 58 ]. The ideal composition and amount of fat in nutritional support for burn patients remains a topic of controversy and warrants further investigation.
Proteolysis is greatly increased after severe burn and can exceed a half pound of skeletal muscle daily [ 59 ]. Protein supplementation is needed to meet ongoing demands and supply substrate for wound healing, immune function, and to minimize the loss of lean body mass. Protein is used as an energy source when calories are limited; however, the opposite is not true.
Giving excess calories will not lead to increased protein synthesis or retention, but rather lead to overfeeding. Supplying supranormal doses of protein does not reduce the catabolism of endogenous protein stores, but it does facilitate protein synthesis and reduces negative nitrogen balance [ 60 ]. Currently, protein requirements are estimated as 1.
Non-protein calorie to nitrogen ratio should be maintained between for smaller burns and for larger burns [ 61 ]. Even at these high rates of replacement, most burn patients will experience some loss of muscle protein due to the hormonal and proinflammatory response to burn injury. Several amino acids are important and play unique roles in recovery after burn.
Skeletal muscle and organ efflux of glutamine, alanine, and arginine are increased after burn. These amino acids are important for transport and help supply energy to the liver and healing wounds [ 62 ]. Glutamine directly provides fuel for lymphocytes and enterocytes and is essential for maintaining small bowel integrity and preserving gut-associated immune function [ 63 , 64 ].
Glutamine also provides some level of cellular protection after stress, as it increases the production of heat shock proteins and it is a precursor of glutathione, a critical antioxidant [ 64 — 66 ].
Arginine is another important amino acid because it stimulates T lymphocytes, augments natural killer cell performance, and accelerates nitric oxide synthesis, which improves resistance to infection [ 69 , 70 ]. The supplementation of arginine in burn patients has led to improvement in wound healing and immune responsiveness [ 70 — 72 ].
Despite some promising results in the burn population, data from critically ill nonburn patients suggest that arginine could potentially be harmful [ 73 ]. The current data is insufficient to definitively recommend its use, and further study is warranted. Severe burn leads to an intense oxidative stress, which combined with the substantial inflammatory response, adds to the depletion of the endogenous antioxidant defenses, which are highly dependent on micronutrients [ 74 , 75 ].
Decreased levels of vitamins A, C, and D and Fe, Cu, Se, and Zn have been found to negatively impact wound healing and skeletal and immune function [ 76 — 78 ].
Vitamin A decreases time of wound healing via increased epithelial growth, and vitamin C aids collagen creation and cross-linking [ 79 ]. Vitamin D contributes to bone density and is deficient after burn, but its exact role and optimal dose after severe burn remains unclear.
Pediatric burn patients can suffer significant dysfunction of their calcium and vitamin D homeostasis for a number of reasons. Children with severe burn have increased bone resorption, osteoblast apoptosis, and urinary calcium wasting. Additionally, burned skin is not able to manufacture normal quantities of vitamin D3 leading to further derangements in calcium and vitamin D levels.
A study of pediatric burn patients found that supplementation with a multivitamin containing IU of vitamin D2 did not correct vitamin D insufficiency [ 80 — 82 ].
More investigation into therapies to combat calcium and vitamin D deficiency is needed. The trace elements Fe, Cu, Se, and Zn are important for cellular and humoral immunity, but they are lost in large quantities with the exudative burn wound losses [ 77 ]. Zn is critical for wound healing, lymphocyte function, DNA replication, and protein synthesis [ 83 ]. Fe acts as a cofactor for oxygen-carrying proteins, and Se boosts cell-mediated immunity [ 75 , 84 ]. Cu is crucial for wound healing and collagen synthesis, and Cu deficiency has been implicated in arrhythmias, decreased immunity, and worse outcomes after burn [ 85 ].
Replacement of these micronutrients has been shown to improve the morbidity of severely burned patients Table 2 [ 2 , 75 , 86 , 87 ]. PN was routinely used for burn patients in the s and s, but it has been almost completely replaced by EN [ 88 ]. Studies found that PN, alone or in conjunction with EN, is associated with overfeeding, liver dysfunction, decreased immune response, and three-fold increased mortality [ 89 , 90 ].
PN also appears to increase the secretion of proinflammatory mediators, including TNF, and also can aggravate fatty infiltration of the liver [ 91 , 92 ]. In addition to these issues, PN has more mechanical and infectious complications of catheters, and PN solutions are significantly more expensive than EN formulas.
EN, in addition to being a safe and cost effective feeding route, has been found to have many advantages. The presence of nutrients within the lumen of the bowel promotes function of the intestinal cells, preserves mucosal architecture and function, stimulates blood supply, decreases bacterial translocation, and improves gut-associated immune function [ 36 , 39 ].
For all of these reasons, EN is the route of choice for severely burned patients. EN can be administered as either gastric or post-pyloric feedings, and both are widely used. Gastric feeding has the advantages of larger diameter tubes, which have less clogging and the ability to give bolus feeds; however, the stomach often develops ileus in the postburn state.
Smaller post-pyloric tubes are more prone to clogging and malposition, but they are often more comfortable and post-pyloric feedings can be safely continued even during surgical procedures to sustain caloric goals without an increased risk of aspiration [ 93 ]. Despite the strong preference to give nutritional support primarily via the gastrointestinal tract, PN can be used in burned patients in whom EN is contraindicated.
Further research is warranted regarding if parenteral supplementation of specific dietary components, such as amino acids alone, would be beneficial.
PN and EN are usually given in a continuous fashion. The earliest formulas for burn patients consisted of milk and eggs, and although these simple mixtures were relatively successful at providing adequate nutrition, they were very high in fat. Numerous commercially prepared enteral formulas have been developed since that time, all with differing amounts of carbohydrates, protein, fats, and micronutrients Table 3. Glucose is the preferred energy source for burn patients and they should therefore be administered a high-carbohydrate diet [ 47 , 94 ].
Immune-enhancing diets, or immunonutrition, are nutritional formulas that have been enriched with micronutrients in an effort to improve immune function and wound healing.
These formulas gained attention after Gottschlich et al. This led to the commercial production of similar immune-enhancing diets. Subsequent study of these formulas has shown that they lead to an improvement in neutrophil recruitment, respiratory gas exchange, cardiopulmonary function, mechanical ventilation days, and length of stay in some nonburn populations [ 98 , 99 ].
Studies in patients with sepsis and pneumonia, however, suggest immune-enhancing diets could have a harmful effect [ 73 , 98 ]. Little research exists regarding immune-enhancing diets in the burn population. A small study by Saffle et al. It has been theorized that because of the high volume of feedings given to burn patients, they may receive a satisfactory dose of most immune-enhancing nutrients with the use of conventional diets. A multitude of formulas and numerous methods for calculating nutritional needs are used successfully in the burn population, which suggests that no formula or calculation is perfect, but most are adequate to prevent nutritional complications.
The study of nutrition and metabolism in burn patients is difficult to perform in an exacting and precise method because both the pathophysiology of burn injury and the treatment modalities during the course of burn care are very complex.
The effects of differing compositions of nutritional support can easily be confounded by variations in treatment modalities and the complicated pathophysiology of individual burn patients at different stages of their treatment course. A single burn unit takes a very long time to gather data from enough patients which could introduce confounders as other treatment methods advance and change.
Multi-institutional trials are also difficult, and any difference in treatment protocols among institutions could overshadow effects of differing nutritional support. A wide range of clinical trials on different nutritional regimens are still being carried out and have not reached convincing consensus on optimal nutrition for burn patients.
The rate of obesity has rapidly grown over the past 30 years in both the USA and worldwide [ ]. Approximately two thirds of the US population are overweight, and one third meet the BMI criteria for obese [ ].
In the general population, obesity is clearly linked with multiple health problems including diabetes, cardiovascular disease, arthritis, and morbidity [ ]. Strangely, overweight and moderately obese patients in surgical and medical intensive care units have been found to have a reduced mortality compared to normal weight patents, despite a higher rate of infections and longer length of stay [ , ].
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