THE PAPWORTH PLUG - successful use of high dose fibrinogen concentrate and platelet concentrate in potential life-threatening complication after cardiopulmonary bypass surgery in a patient with Type 2M Vicenza von Willebrand Disease

Anecdotally, fibrinogen concentrate (FC) has been used as a "universal" haemostatic agent in complex post-cardiopulmonary bypass (CPB) coagulopathy. We present a case where FC and two pools of platelets prevented life-threatening bleeding in a patient with moderate von Willebrand Disease (vWD) immediately post CPB.

Developments in mycotoxin analysis: an update for 2010-2011

This review highlights developments in mycotoxin analysis and sampling over a period between mid-2010 and mid-2011. It covers the major mycotoxins: aflatoxins, Alternaria toxins, ergot alkaloids, fumonisins, ochratoxin, patulin, trichothecenes, and zearalenone. Analytical methods for mycotoxins continue to be developed and published. Despite much interest in immunochemical methods and in the rapid development of LC-MS methodology, more conventional methods, sometimes linked to novel clean-up protocols, have also been the subject of research publications over the above period. Occurrence of mycotoxins falls outside the main focus of this review; however, where relevant to analytical method development, this has been mentioned.

Developments in mycotoxin analysis: an update for 2009-2010

This review highlights developments in mycotoxin analysis and sampling over a period between mid-2009 and mid-2010. It covers the major mycotoxins aflatoxins, Alternaria toxins, ergot alkaloids, fumonisins, ochratoxin, patulin, trichothecenes, and zearalenone. New and improved methods for mycotoxins continue to be published. Immunological-based method developments continue to be of wide interest in a broad range of formats. Multimycotoxin determination by LC-MS/MS is now being targeted at the specific ranges of mycotoxins and matrices of interest or concern to the individual laboratory. Although falling outside the main emphasis of the review, some aspects of natural occurrence have been mentioned, especially if linked to novel method developments.

Determination of fumonisins B1 and B2 in corn by LC/MS with immunoaffinity column cleanup: interlaboratory study

An interlaboratory validation study was conducted to establish the method performance characteristics of an immunoaffinity column (IAC) cleanup procedure followed by LC/MS for the determination of fumonisins B1 (FB1) and B2 (FB2) and combined FB1 + FB2 in corn. The test portion is extracted with acetonitrile-methanol-water (25 + 25 + 50). The extract is filtered, diluted with phosphate-buffered saline solution, and applied to an IAC. FB1 and FB2 are removed with methanol, followed by water, then directly determined by RPLC with MS detection using selected-ion monitoring of two characteristic ions in each case. Naturally contaminated corn samples were milled to a fine powder and mixed to produce three samples with target levels of combined FB1 + FB2 ranging from 350 to 4000 microg/kg. Of 15 initially participating laboratories, two failed to report results and another did not follow the prescribed method. Thus, valid results were obtained from 12 participants located in 11 countries. Statistical analysis of the results produced RSDr values of 4.6-11.9, 1.9-12.6, and 1.4-11.5% for FB1, FB2, and combined FB1 + FB2, respectively; the corresponding RSDR values were 19.8-23.8, 18.2-25.5, and 18.8-23.2%. The three concentration levels of combined FB1 + FB2 were 534, 1194, and 1954 microg/kg. HorRat values for r and R were all < 2.0, indicating that the method is suitable as a regulatory method for the enforcement of European Union limits for fumonisins in corn.

Characterization and time course of pulmonary lesions in calves after intratracheal infection with Pasteurella multocida A:3

Pasteurella multocida A:3 is a common cause of suppurative bronchopneumonia in calves and results in significant production losses and mortality. Here we describe the lesions in three calves at each of four time points (1 day and 4, 7 and 10 days) after experimental intratracheal infection with approximately 1x10(9) colony-forming units of P. multocida A:3 Moredun Research Institute (MRI isolate 671/90). Equivalent age- and time-matched sham-dosed negative control animals were also studied. Infected calves developed significantly elevated mean rectal temperatures (P<0.001) and respiratory rates (P<0.001) compared with negative control animals. Extensive consolidation of multiple lung lobes was present on each of the day/s post-infection (dpi). Histologically, large numbers of alveoli contained either or both polymorphonuclear neutrophils (PMNs) and oedema fluid (1 dpi). At 4 dpi a severe fibrinosuppurative bronchopneumonia had developed. At this time, PMNs and macrophages formed focal lesions containing central necrotic and mineralized debris, while the interlobular septa were severely distended by oedema. Early abscess formation was present in the lung parenchyma at 7 dpi and many of the interlobular septa were thrombosed. At 10 dpi abscesses within the lung parenchyma were mature and comprised of central necrosis with surrounding layers of PMN, macrophages and fibrous tissue. This study describes, for the first time, the commencement, nature and progression of lesions in bovine pneumonic pasteurellosis caused by P. multocida A:3 and provides the foundations for further investigation of the pathogenesis of this disease in cattle.

Strategies for avoidance of nonembolic stroke during carotid artery stenting

Over the last decade many technical and pharmacological advances were made in order to improve the safety profile of carotid artery stenting (CAS). These advances largely addressed the issue of embolic stroke. It is clear, however, that despite each of these advances, which include dedicated carotid stents in place of adapted peripheral or coronary designs, low-profile rapid-exchange 0.014''-compatible equipment, cerebral protection devices and improvements in pharmacological support, there remains a finite risk of stroke and death associated with CAS. For example, the influence of one of these factors, the use of cerebral protection, employed in order to prevent embolic stroke, cannot be seen to be a panacea against procedural stroke. The 30-day results from the randomised trial SPACE, comparing CAS and carotid endarterectomy, indicated that the ipsilateral stroke and death rate was 7.3% in those patients in whom protection had been employed and 6.7% in unprotected patients. Clearly procedural stroke may result from other, nonembolic means such as haemodynamic disturbances and acute carotid occlusions. These factors must be recognised, considered, pre-empted and appropriately managed in order to further impact on the procedural event rate.

Congenital heart defects in Canadian Inuit: is more folic acid making a difference?

INTRODUCTION

Grain fortification of flour with folic acid has successfully reduced neural tube defects (NTDs) by approximately one half of the pre-fortification rate. The knowledge that the use of multivitamins with folic acid has also been shown to reduce some birth defects has prompted interest in determining whether folic acid may also play a role in the prevention of non-neural tube defects. Although NTDs are not more frequent in the Inuit of the Eastern Arctic, septal heart defects, were documented pre-fortification (1989-1994) to be increased 4 fold.

OBJECTIVES

To determine if current efforts of fortification are sufficient and to explore other genetic/ environmental determinants of the increased rate of septal heart defects in the Eastern Arctic.

METHODS

Inuit mothers of children from communities on Baffin Island with and without heart defects were invited to participate in a case control study evaluating nutrient intake, pregnancy exposures, RBC folate, serum cobalamin, homocysteine, and functional polymorphisms for genes important in folate metabolism and uptake.

RESULTS

41 children with isolated heart defects and their mothers with 36 community matched Inuit controls have entered the study to date.

RESULTS

There were no differences in RBC folate (953 Vs 922 nmol/L p = .49), serum cobalamin, and homocysteine, between mothers of cases and controls. The combined average RBC folate for the women ages 18-45 was 947 +/- 32 nmol/L. There was no difference between any documented alcohol (H"30%) and cigarette (H"82%) use in pregnancy. No Inuit women were taking vitamins at conception or at the time of this study. The results of the genetic studies will be reported elsewhere.

CONCLUSIONS

RBC folate (post-fortification) in our sample of women of childbearing years is reassuring. However, it is possible that pre-fortification levels combined with genetic predisposition may have previously influenced the high rate of heart defects. Follow-up study is underway to determine if rates of heart defects have decreased since fortification was commenced. Since folate alone may not be sufficient to reduce non-neural tube defects, culturally appropriate public health efforts need to be initiated to encourage multivitamin use periconceptionally.

Survey of pigs' kidneys with lesions consistent with PMWS and PDNS and ochratoxicosis. Part 2: pathological and histological findings

One thousand condemned pigs' kidneys were collected in February 2002 from two pig abattoirs in England to assess the lesions due to postweaning multisystemic wasting syndrome (pmws) and porcine dermatitis and nephropathy syndrome (pdns) and the possible contribution of ochratoxicosis; 174 of the kidneys were pale, 295 were swollen and 81 were abnormally firm with the gross appearance of fibrosis. The main macroscopic finding was the presence of multifocal pale cortical lesions, observed in 446 of the kidneys, and there were large cysts in 266 of them. Histopathological lesions of non-suppurative tubulointerstitial nephritis, with degeneration and fibrosis of renal tubules, were identified in 213 of 250 (85.2 per cent) of the kidneys examined. These lesions were consistent with those reported in cases of pmws and pdns. The tubular degeneration and fibrosis were also consistent with ochratoxicosis. A higher mean concentration of ochratoxin A was significantly (P=0.020) associated with the presence of multifocal pale cortical lesions consistent with ochratoxicosis, but a causal relationship was not confirmed because histochemistry was not used to detect ochratoxin in the lesions directly. There was no significant correlation between the microscopic lesions and the concentration of ochratoxin. The degenerative lesions may have been caused by previous exposure to ochratoxin that had subsequently been excreted, but the microscopic lesions also included non-suppurative interstitial nephritis, which was unlikely to have been caused by ochratoxicosis.

Exposure of garden birds to aflatoxins in Britain

Aflatoxins are potent biological toxins that have been shown to exert a range of acute and chronic pathological effects. Multiple mortality events of waterfowl caused by acute aflatoxicosis have been documented in the USA. However, international concern has recently been expressed regarding the potential effects of chronic exposure of wildlife species to low levels of dietary aflatoxin. This study documents for the first time the presence of hepatic aflatoxin residues in British wild birds: two passerine species, the house sparrow (Passer domesticus) and greenfinch (Carduelis chloris). Further research is required to investigate the source of the dietary aflatoxins and their pathological significance, if any, for wild birds in Britain.

Assessment of subtle cognitive-communication deficits following acquired brain injury: A normative study of the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)

PRIMARY OBJECTIVE

To present a new measure, the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), with evidence for its reliability and validity in a normative study. The FAVRES is designed to evaluate the subtle cognitive-communication deficits of individuals with ABI.

METHODS AND PROCEDURES

The FAVRES consists of four complex, contextually rich, verbal reasoning tasks that simulate everyday situations and require processing of text and discourse. Scoring considers the time, accuracy and justification of reasoning responses. The FAVRES scores of 52 adults with ABI were compared to those of 101 adults without ABI.

OUTCOMES

FAVRES scores clearly differentiated the performances of individuals with and without ABI. Individuals with ABI were slower and less accurate in reasoning and presented fewer adequate rationales for their decisions. Inter-rater reliability for scoring was acceptable.

CONCLUSIONS

The FAVRES provides a reliable, functional and quantifiable measure of the cognitive-communication difficulties of individuals with ABI.

Coronary artery bypass graft imaging using ECG-gated multislice computed tomography: Comparison with catheter angiography

AIM

To compare the value of multislice computerized tomography (MSCT) in imaging coronary artery bypass grafts (CABGs) by direct quantitative comparison with standard invasive angiography.

METHODS

Using MSCT, 50 consecutive patients who had previously undergone CABG surgery and had recently undergone invasive angiography for recurrent angina pectoris, were studied further using MSCT after intravenous injection of non-ionic contrast agent; cardiac imaging was performed during a single breath-hold. Graft anatomy was quantified, using both quantitative coronary angiography (QCA) and MSCT, by different investigators blinded to each other. Reproducibility was quantified using the standard error of the measurement expressed as a percentage in log-transformed values (CV%) and intraclass correlation (ICC).

RESULTS

All 150 grafts were imaged using MSCT; only 4 patent grafts were not imaged using selective angiography. Good agreement was achieved between MSCT and QCA on assessment of proximal anastomoses (CV% 25.2, ICC 0.84), mid-vessel luminal diameter (CV% 15.5, ICC 0.91) and aneurysmal dilations (CV% 14.3). Reasonable agreement was reached on assessment of distal anastomoses (CV% 26.7, ICC 0.66) and categorization of distal run-off (ICC 0.73). Good agreement was observed for stenoses of over 50% luminal loss (CV% 8.7, ICC 0.97) but agreement on assessment of less severe lesions was poor (CV% 208.7, ICC 0.51).

CONCLUSION

This study demonstrates that CABGs can be quantitatively evaluated using MSCT, and that significant lesions present in all CABG segments can be reliably identified. Agreement between MSCT and QCA for lesions of less than 50% luminal loss was poor.

Determination of ochratoxin A in green coffee by immunoaffinity column cleanup and liquid chomatography: collaborative study

A collaborative study was conducted to evaluate a method using immunoaffinity column cleanup with liquid chromatography (LC) for the determination of ochratoxin A (OTA) in green coffee at levels that could be included in possible future regulations of the European Union. The test portion was extracted with methanol-3% aqueous sodium hydrogen carbonate solution (50 + 50, v/v). The extract was filtered, and the filtrate was diluted with phosphate-buffered saline and applied to an immunoaffinity column containing antibodies specific for OTA. After washing, the toxin was eluted from the column with methanol and quantified by LC with fluorescence detection. Pairs of 4 homogeneous noncontaminated and naturally contaminated materials (mean levels of < 0.12, 2.44, 5.15, and 13.46 ng/g) and blank samples (< 0.12 ng/g) for spiking were sent to 20 participant laboratories from 8 countries. The materials were analyzed according to the method description and all difficulties encountered in the analysis were reported. Statistical analysis was carried out according to the Harmonized Protocol of the International Union of Pure and Applied Chemistry. The relative standard deviation for repeatability (RSDr) ranged from 7.42 to 20.94%, and the relative standard deviation for reproducibility (RSDR) ranged from 16.34 to 29.17%. The method showed acceptable within-laboratory and between-laboratories precision for green coffee materials, as evidenced by HorRat values of < or = 0.85, at the studied range, for spiked and naturally contaminated materials. The mean recovery was 92.8% for green coffee material spiked with OTA at a level of 4.82 ng/g.

Survey of ochratoxin A and deoxynivalenol in stored grains from the 1999 harvest in the UK

Three hundred and twenty samples from the 1999 UK harvest comprising wheat (201 samples), barley (106) and oats (13) were analysed for ochratoxin A and deoxynivalenol. A small number of organic samples was also obtained. Samples were collected from farms, central stores, mills, maltings and ports from across the UK from February to April 2000. Ochratoxin A and deoxynivalenol analysis was by affinity column clean up and high-performance liquid chromatography with fluorescence and ultraviolet light detection, respectively, with limits of detection of 0.2 and 20 microg kg(-1). The survey found ochratoxin A at below 5 microg kg(-1) in 97% of the samples indicating satisfactory storage conditions. The remaining 3% of the samples contained ochratoxin A at levels between 5.2 and 231 microg kg(-1), but none of these samples was intended for human consumption. Deoxynivalenol was detected in 88% of all samples, with 83% below 100 microg kg(-1); the maximum level was 600 microg kg(-1). Twenty samples containing deoxynivalenol at or above 150 microg kg(-1) by high-performance liquid chromatography were all confirmed by gas chromatography/mass spectrometry. Nivalenol was also detected by gas chromatography/mass spectrometry at levels of 50 microg kg(-1) or higher in 18 of 20 samples where deoxynivalenol was confirmed.

A capture-recapture model to estimate prevalence of children born in Scotland with developmental eye defects

BACKGROUND

Microphthalmia, anophthalmia and coloboma (MAC) are closely related structural developmental eye defects that have caused public concern in the UK following media reports of apparent clusters of cases. An extensive search was carried out to identify potential cases, and diagnoses were confirmed by ophthalmological review. Despite this effort, it was recognised that some cases would remain unidentified. Capture-recapture methods could improve the accuracy of the study's birth prevalence estimate.

METHODS

A register of all children born with the developmental eye defects of MAC in Scotland (1981-96) was compiled. This identified 188 cases from eight national ascertainment sources. The methods described by Hook and Regal were used to determine possible estimates for each source. A log-linear method of capture-recapture was used to fit a model to the number of children identified by the different combinations of the eight national sources, and the individual sources were included in the model as main effects.

RESULTS

Maximum-likelihood estimates were calculated for tables of captured/not captured by one source versus any other source. The estimated number of unobserved cases for the most complete source, the register of congenital anomalies for Scotland, and the seven others combined is 78 (95% CI 53-115). Estimates calculated from two different log-linear models of the numbers of cases unobserved by all sources were 61 (95% CI 43-86) and 175 (95% CI 106-287). An external check with an independent congenital-anomalies register in one region, which is known to have high completeness, gave an estimate of 120. The study found a birth prevalence of MAC in Scotland of 1.9/10000, based on total live births during the study period. The capture-recapture analysis suggests that the true birth prevalence lies between 2.4/10 000 and 3.5/10000.

DISCUSSION

Our experience shows that, even with multiple sources of ascertainment and considerable resources directed at case identification, a considerable level of under-ascertainment of congenital eye-anomalies still results, and suggests that the use of capture-recapture analysis would be a useful addition to congenital anomalies registers for needs assessment, disease-burden estimates and health-service planning.

Experimental one year ochratoxin A toxicosis in pigs

Mild mycotoxic nephropathy was induced in 6 pigs by a diet containing ochratoxin A at 800 ppb, several times higher than that naturally encountered in some feed for pig production in Bulgaria. The nephropathy was expressed only as slightly hypertrophied kidneys with a faintly mottled surface, discernible at the end of the experiment to a skilled observer but probably not recognisable in routine slaughterhouse processing. Histological examination showed two types of changes: degenerative - affecting epithelial cells in some proximal tubules of pigs after 6 months, and proliferative changes in the interstitium which predominated after 1 year of exposure to ochratoxin A. Telangiectasis and lymph stasis were rarely seen. The renal lesions were similar to those described for classical mycotoxic porcine nephropathy formerly encountered in Denmark, but they were rather different from the porcine nephropathy which occurs spontaneously in Bulgaria. Measurement of ochratoxin A in serum provided analytical values complementary to feed intake and with similar concentration values. It also showed both accumulation with time, from 3 months to 6 months (approximately 1 ppm), and a 2-fold range of values within a group eating from a common feed source, as in commercial pig production. Mild symptomatology in this long, single-mycotoxin experiment serves to lessen somewhat the current perception of the direct renal toxicity of ochratoxin A alone, though a role in multi-toxin contexts is unquestioned.

Assessment of dietary exposure to ochratoxin A in the UK using a duplicate diet approach and analysis of urine and plasma samples

The approach to assess exposure to ochratoxin A from the diet by the analysis of human plasma and urine samples has been developed. Composite duplicate diet samples from 50 individuals and corresponding plasma and urine samples were obtained over 30 days. Samples were analysed using sensitive methods capable of measuring ochratoxin A at 0.001 ng g(-1) in food, 0.1 ng ml(-1) in plasma and 0.01 ng ml(-1) in urine. Analysis of the foods indicated ochratoxin A levels contributing to an average intake in the range 0.26-3.54 ng kg(-1) bw day(-1) over the 30 days. Ochratoxin A was found in all plasma samples and in 46 urine samples. The correlation between the plasma ochratoxin A levels and ochratoxin A consumption was not significant (95% confidence limit). However, a significant correlation was found between ochratoxin A consumption and the urine ochratoxin A concentration expressed as the total amount excreted. This new work offers the possibility of using ochratoxin A in urine as a simple and reliable biomarker to estimate exposure to this mycotoxin.

Posterior-stabilized and cruciate-retaining total knee replacement: a randomized study

A randomized controlled study was done to compare the clinical, radiographic, and quality of life outcomes between posterior-stabilized and cruciate-retaining primary total knee implants. One hundred forty-three patients were enrolled in the study. Patients ranged in age from 57 to 89 years, had a primary diagnosis of osteoarthritis, and an intact functioning posterior cruciate ligament. Patients were excluded if they had a flexion contracture greater than 15 degrees, a varus deformity greater than 20 degrees, or a valgus deformity greater than 15 degrees. Patients were randomized to one of two study groups, posterior-stabilized AMK total knee implants (76 patients) or cruciate-retaining AMK total knee implants (67 patients). One hundred eight patients have had a minimum 2-year followup including 57 patients in the posterior-stabilized group and 51 patients in the cruciate-retaining group. Seventy-three patients have had a minimum 3-year followup including 37 patients in the posterior stabilized group and 36 patients in the cruciate-retaining group. The overall total Knee Society clinical rating score at 2 years averaged 157.1 points in the posterior-stabilized group and 156.5 points in the cruciate-retaining group. At 3 years, the scores averaged 156.8 points in the posterior-stabilized group and 163.5 points in the cruciate-retaining group. The range of motion component of the Knee Society score averaged 113.6 degrees for the posterior-stabilized group and 108.5 degrees for the cruciate-retaining group at 2 years, and 108.3 degrees in the cruciate-retaining group and 108.5 degrees in the posterior-stabilized group. Based on the various parameters analyzed, there were no notable differences between the groups with a posterior-stabilized and a cruciate-retaining total knee implant at 2 years. This trend seemed to be the same at 3 years.

Looking over the horizon: an Internet-based international course in healthcare management

The International Course in Healthcare Management is predicated on the belief that comparative benefits can most effectively be 'taught' by enabling students to work directly with colleagues in other countries, sharing views, discussing differences, and checking understandings on how healthcare is structured and managed in different countries. The course focuses on four countries--Canada, Germany, Finland and Ireland--which offer an interesting range and mix of approaches to healthcare, and yet are sufficiently similar to ensure relative ease of understanding. The course, which is delivered and taught jointly by faculty from five participating institutions in the four countries using the Internet as the distance delivery medium, is an integral component of each institution's participating department's graduate program. The aims of the course are: to enable the participants to develop an in-depth understanding of the healthcare systems of each country; to foster a deeper understanding, through comparative analysis, of each participant's own healthcare system; and to facilitate the development of new insights into ways of addressing common concerns in healthcare management. The course is structured around a series of case studies organized under four main themes: financing and funding; delivery issues; impact of health service reforms; and evidence-based management.

Orthotopic liver transplantation using low-dose tacrolimus and sirolimus

Although sirolimus (SRL) binds the immunophilin FK506-binding protein-12 (FKBP-12) with greater avidity than tacrolimus (TAC), animal studies have shown that SRL and TAC act synergistically to prevent rejection. Dose-related toxicity is more often the cause of TAC discontinuation than rejection. We hypothesized that SRL would allow for a substantial reduction in the concomitant dose of TAC after liver transplantation to levels less than the threshold for toxicity. A series of 56 liver transplant recipients were administered a combination of SRL and TAC (target trough levels, 7 and 5 ng/mL, respectively). Planned weaning of steroids commenced after 3 months. Pharmacokinetic (PK) studies were undertaken. Patient and graft survival were 52 patients (93%) and 51 grafts (91%), with a follow-up of 23 months (range, 6 to 35 months). One episode (1.8%) of hepatic artery thrombosis was seen. The rate of acute cellular rejection was 14%. No extra treatment was administered in 3 of 8 patients, and the other 5 episodes responded to a single course of steroids. Cytomegalovirus infection occurred in 4 patients (7%). Renal function, glucose control, and lipid metabolism are near normal in 47 patients (84%) without additional medication. Steroid elimination is completed in 51 patients (91%). Bioavailability of SRL and TAC varied between transplant recipients, but trough levels strongly correlated with the area under the curve (r(2) = 0.82 and r(2) = 0.84, respectively). Simultaneous administration did not affect the PK profile of the drugs at this dose. The ratio of trough level to daily dose correlated between SRL and TAC. The synergistic effect seen in animal models also occurs in clinical liver transplant recipients on SRL-TAC combination immunosuppression. A low-dose combination of SRL and TAC should be compared with conventional immunosuppression in a multicenter, randomized, controlled trial.

Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial

OBJECTIVE

To determine the extent to which postpyloric feeding reduces gastroesophageal regurgitation and pulmonary microaspiration in critically ill patients.

DESIGN

Randomized trial.

SETTING

A medical/surgical intensive care unit at a tertiary care hospital.

PARTICIPANTS

Intensive care unit patients were expected to remain ventilated >72 hrs. We excluded patients with esophageal, gastric, or small bowel surgery in the last week and patients with overt or clinically significant gastrointestinal bleeding. We studied 33 patients; 42.4% were female, mean age (sd) was 59.2 (+/- 16.8) yrs, and mean Acute Physiology and Chronic Health Evaluation II score was 22.5 (7.8).

INTERVENTIONS

Patients were randomized to gastric or postpyloric enteral feeds. Technetium 99-sulphur colloid was added to the feeds for 6 hrs of each of the first 3 days on study.

MEASUREMENTS AND RESULTS

We sampled the oropharynx and trachea hourly for the 6 hrs per day that patients received radioisotope-labeled enteral feeds, and the level of radioactivity in these specimens was measured. We defined an episode of gastroesophageal regurgitation and microaspiration as an increase in radioactivity >100 counts per minute/g. Patients fed into the stomach had more episodes of gastroesophageal regurgitation (39.8% vs. 24.9%, p =.04) and trended toward more microaspiration (7.5% vs. 3.9%, p =.22) compared with patients fed beyond the pylorus. When the logarithmic mean of the radioactivity count was compared across groups, there was a trend toward an increase in gastroesophageal regurgitation (3.7 vs. 2.9 counts/g, p =.22) and a trend toward increased microaspiration (1.9 vs. 1.4 counts/g, p =.09) in patients fed into the stomach. Patients who had gastroesophageal regurgitation were much more likely to aspirate than patients who did not have gastroesophageal regurgitation (odds ratio: 3.2; 95% confidence interval: 1.36, 7.77).

CONCLUSIONS

Feeding beyond the pylorus is associated with a significant reduction in gastroesophageal regurgitation and a trend toward less microaspiration.

Total parenteral nutrition in the surgical patient: a meta-analysis

OBJECTIVE

To examine the relationship between total parenteral nutrition(TPN) and complication and death rates in surgical patients.

DATA SOURCES

A computer search of published research on MEDLINE, personal files and a review of relevant reference lists.

STUDY SELECTION

A review of 237 titles, abstracts or papers. Primary studies were included if they were randomized clinical trials of surgical patients that evaluated the effect of TPN (compared to no TPN or standard care) on complication and death rates. Studies comparing TPN to enteral nutrition (EN) were excluded.

DATA EXTRACTION

Relevant data were abstracted on the methodology and outcomes of primary studies. Data were independently abstracted in duplicate.

DATA SYNTHESIS

There were 27 randomized trials in surgical patients that compared the use of TPN to standard care (usual oral diet plus intravenous dextrose). When the results of these trials were aggregated, there was no effect on mortality (risk ratio = 0.97, 95% confidence intervals, 0.76 to 1.24). There were fewer major complications in patients who received TPN, although there was significant heterogeneity in the overall estimate (risk ratio = 0.81, 95% CI, 0.65 to 1.01). Because of this significant heterogeneity, several a priori hypotheses were examined. Studies that included only malnourished patients demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies of patients who were not malnourished. Studies published in 1988 or earlier and studies with a lower methods score were associated with a significant reduction in complication rates and a trend to a reduction in death rate when compared with studies published after 1988 and studies with a higher methods score. There was no difference in studies that provided lipids as a component of TPN when compared with studies that did not. Studies that initiated TPN preoperatively demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies that initiated TPN postoperatively.

CONCLUSIONS

TPN does not influence the death rate of surgical patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by methodologic quality and year of publication.