Esophageal obstruction by solidification of the enteral feed: a complication to be prevented

We report three cases of esophageal obstruction due to solidification of enteral feed refluxed from the stomach in patients being fed through a nasogastric tube. All three patients were administered sucralfate continuously by tube. The few previous descriptions of this rare complication have also implicated sucralfate with its pathogenesis. Given its clinical importance and the growing use of long-term enteral nutrition, this adverse event needs to be considered.

[Evaluation of energy metabolism in burn patients: indirect calorimetry predictive equations]

INTRODUCTION

Knowing the most reliable method for measuring the metabolic energy use (MEU), is of great importance in patients with severe burns. For the calculation of the energetic requirements of large burn patients, several predictive equations (PE's) are used, based on weight, size, age, body surface area (BSA), and burned body surface (BBS). Previous studies note the tendency for over-or underestimating the MEU, depending on whether one or another PE is used, which is why it is considered necessary to calculate the energy requirements in the most exact manner possible, which can be done by means of indirect calorimetry (IC).

MATERIAL AND METHODS

18 patients (14 men and 4 women) who were admitted to the Burn Unit between 1994 and 1995, were included in the study, with the following inclusion criteria; age > 18 years and < 65 years, and who presented deep burns on are than 15% of the body surface. The MEU of the patients was evaluated by means of IC, using a Deltatrac il unit. The MEU calculated by means of IC was compared with that calculated by means of the four most commonly used PE's in literature: Long Formula: MEU = Basal energy use (BEU) x activity factor x aggression factor which is variable according to the BBS; Curreri Formula: MEU = (Weight x 25) + (total BBS x 40); MEU = 2000 x BSA. As statistical methods, one looked for the existence of correlation, by means of the Pearson method, and the "r" were compared by means of the Fischer conversion. The regression coefficient was found among the values obtained through the PE's and those measured by IC, as well as among those of IC and the percentage of deep burn and the total burned body surface.

RESULTS

All the formulate included overestimated the MEU measured between 30.6% and 43.8% with the 2 x MEU formula being the one which did so least (30.6%). In any of them, there is an important variation of the percentage of overestimation with respect to the average MEU in this group. All are correlated in an important way with the MEU. The reliability of these PE's is variable, as is shown by the slopes of the regression lines, with the most reliable PE being that of 2000 x BSA, and that of 2 x MEU, by Harris-Benedict. There is also correlation between the average MEU by IC and the deeply burned body surface.

CONCLUSION

This study proves the usefulness of the IC for knowing the EME in burn patients, to prevent their hypernutrition, as well as the relative value of the formulae usually used clinically to estimate this parameter.

Evidence of aspirin use in both upper and lower gastrointestinal perforation

BACKGROUND & AIMS

Current studies lack appropriate data on aspirin and other risk factors for gastrointestinal perforation. The aim of this study was to obtain the best estimate on aspirin and nonaspirin nonsteroidal anti-inflammatory drug (NSAID) use in these patients.

METHODS

In 76 consecutive patients with gastrointestinal perforation and 152 matched controls, a detailed clinical history supplemented with an objective test of current aspirin use (platelet cyclooxygenase activity) was obtained.

RESULTS

Of the 76 cases, 78.9% were upper and 21% lower gastrointestinal perforations. Evidence of NSAID use was found in 71% of cases (70% upper, 75% lower) vs. 26.9% of controls (odds ratio, 6.64; 95% confidence interval, 3.6-12.2; P < 0.0001). The objective test showed 12.7% more aspirin users than clinical history alone. NSAID use was aspirin (alone or combined) in 66.6% of cases, and 59.25% was nonprescription. Other independent risk factors were smoking, alcohol, and a history of arthritis or peptic ulcer but not a positive Helicobacter pylori serology. Age, but not NSAID use, affected perforation-associated mortality.

CONCLUSIONS

NSAID use is strongly associated with an increased risk of both upper and lower gastrointestinal perforation. The high prevalence of aspirin (over-the-counter) use suggests that future introduction of new NSAIDs may not have a major impact on decreasing gastrointestinal complications if other measures are not taken. Concomitant NSAID use, smoking, and alcohol use is a pervasive association.

Influence of type of dietary fat (olive and sunflower oil) upon gastric acid secretion and release of gastrin, somatostatin, and peptide YY in man

The effects of adaptation to two diets differing in the type of dietary fat on the gastric acid secretory response to food and on the circulating levels of gastrin, somatostatin and peptide YY (PYY) were examined in humans. The study involved 18 cholecystectomized subjects previously submitted to a 30-day adaptation period to diets containing olive (group O) or sunflower oil (group S) as the fat source. During the experiments, physiological stimulation was achieved by ingestion of 200 ml of oleic acid- (group O) or linoleic acid-enriched (group S) liquid mixed meals. These resulted in an immediate rise in gastric pH. In group S, the return to the premeal value was completed within 60 min, and a further decline to values significantly lower than the basal ones was observed at the end of the study period. In contrast, ingestion of the meal containing olive oil attenuated and prolonged the pH decrease after the meal, this being associated with the suppression of postprandial gastrin response. Food ingestion induced no significant changes in plasma somatostatin concentration in either group, and no significant differences were revealed between them during the basal or postprandial situations. Plasma PYY levels were consistently higher in group O throughout the entire study period, although significance was reached only at resting. In conclusion, our results show that a 30-day adaptation period to diets containing olive oil as the main source of dietary fat results, compared with those containing sunflower oil, in an attenuated gastric secretory function in response to a liquid meal in humans. The effects of olive oil were associated with a suppression of serum gastrin and higher levels of PYY.

[Decrease of the incidence of sepsis syndrome after early enteral nutrition of patients with severe burns]

The objective of this study was to evaluate the effect of early enteral nutrition on the incidence of the septic syndrome as well as its tolerance, in patients with severe burns. We retrospectively studied 64 patients older than 15 years of age, with a greater than 20% burned body surface area. They were divided into 2 groups as a function of the time elapsed between the beginning of Enteral Nutrition and the time of the burning: 23 patients were given Enteral Nutrition within 24 hours after the burn, and in 41 patients the enteral nutrition was started later than 24 hours after sustaining the thermal injury. Both groups were similar with respect to age, sex, percentage of 2nd and 3rd degree burns, incidence of inhalation, and deaths. All patients received the Enteral Nutrition through a nasogastric tube, with administration of a polymeric, hyperprotein and hypocaloric formula through a continuous infusion pump. In our study we saw a reduction of the incidence of the septic syndrome in the patients who received early enteral Nutrition (26%; 6 patients of a total of 23), with respect to those who did non receive early Enteral Nutrition (54%; 22 patients of a total of 41), with a statistical significance of p > 0.05. There were no differences between both groups with respect to the digestive tolerance to Enteral Nutrition. From our study we can deduce that early Enteral Nutrition reduces the incidence of septic complications, without this increasing the digestive intolerance to the same.

Comparison of outdoor and classroom ozone exposures for school children in Mexico City

To evaluate methods of reducing exposure of school children in southwest Mexico City to ambient ozone, outdoor ozone levels were compared to indoor levels under three distinct classroom conditions: windows/doors open, air cleaner off; windows/doors closed, air cleaner off; windows/doors closed, air cleaner on. Repeated two-minute average measurements of ozone were made within five minutes of each other inside and outside of six different school classrooms while children were in the room. Outdoor ozone two-minute average levels varied between 64 and 361 ppb; mean outdoor levels were above 160 ppb for each of the three conditions. Adjusting for outdoor relative humidity, for a mean outdoor ozone concentration of 170 ppb, the mean predicted indoor ozone concentrations were 125.3 (+/- 5.7) ppb with windows/doors open; 35.4 (+/- 4.6) ppb with windows/doors closed, air cleaner on. The mean predicted ratios of indoor to outdoor ozone concentrations were 0.71 (+/- 0.03) with windows/doors open; 0.18 (+/- 0.02) ppb with windows/doors closed, air cleaner off; and 0.15 (+/- 0.02) ppb with windows/doors closed, air cleaner on. As outdoor ozone concentrations increased, indoor ozone concentrations increased more rapidly with windows and doors open than with windows and doors closed. Ozone exposure in Mexican schools may be significantly reduced, and can usually be kept below the World Health Organization (WHO) guideline of 80 ppb, by closing windows and doors even when ambient ozone levels reach 300 ppb or more.

Acute effects of ozone on the pulmonary function of exercising schoolchildren from Mexico City

The acute effects of ozone (O3) on the change in lung function before and after exercise was assessed in 22 boys and 18 girls from 7 1/2 to 11 yr of age tested up to eight times over a 1 1/2-yr period outdoors (under a tarpaulin) at a school in Mexico City. Ozone and particulates were monitored at an adjacent government station, in the school yard, and under the tarp. Subjects were selected to oversample children with chronic respiratory symptoms, although children with active asthma under regular medication or FEV1 < 80% predicted were excluded. Of the participants, 21 had chronic cough, chronic phlegm, or ever wheeze with colds or apart from colds. Children performed two cycles of treadmill exercise (15 min) and rest (15 min) for a total of 1 h of intermittent exercise. Most subjects attained the target minute ventilation of 35 L/min/m2. Subjects exercised alternately during low ozone hours (8:00-10:00 A.M.) and during peak O3 hours (12:00-2:00 P.M.), to assure a range of exposures. On 85% of exercise days, the maximum daily 1-h average for ambient O3 exceeded the Mexican guideline of 110 parts per billion (ppb). O3 exposure during the hour of exercise was divided into quintiles, and the response was adjusted for repeated measures, subject having a cold, and prior outdoor exercise. Ambient O3 in the fifth quintile (mean = 229 ppb) was associated with a percentage change in FVC (-1.43% +/- 0.70), FEV1 (-2.85% +/- 0.79), FEF25-75% (-6.32 +/- 1.87) and FEV1 (-1.41% +/- 0.46).(ABSTRACT TRUNCATED AT 250 WORDS)

[Rapidly-growing renal angiomyolipoma associated with pregnancy]

Renal angiomyolipoma is a relatively uncommon entity which can occur either as a solitary angiomyolipoma or associated to a systemic condition such as Bourneville's disease or tuberous sclerosis. Presentation of one case of a large, fast growing renal angiomyolipoma associated to pregnancy, which required surgery during the third month of pregnancy.

AMPA elicits long-lasting, partly hypothermia-sensitive calcium responses in acutely dissociated or cultured embryonic brainstem cells

This study aimed at testing if, and under which conditions, long-lasting cytosolic calcium responses can be induced in dissociated embryonic brain cells exposed to alpha-amino-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptor agonists. Rat brainstem cells (gestation days 13-14; mean crown-rump lengths 8-11 mm) were mechanically dissociated and loaded with the fluorescent calcium marker Fluo-3 after in vitro delays ranging from 20 min to 6 days. The cells were exposed to various concentrations of AMPA, domoic acid or kainic acid. The evoked fluorescence changes, indicating variations of cytosolic calcium, were recorded and analysed either with a video-microscope or a laser cytometer. Even at the earliest stages, non-desensitizing (or partly desensitizing) calcium responses to AMPA were found. In addition, sequential exposure to AMPA followed either by domoic acid, or by AMPA in the presence of aniracetam, revealed the existence of cells bearing predominantly desensitizing receptors. The non-desensitizing as well as desensitizing response components were blocked by 6,7-dinitroquinoxaline-2,3-dione (DNQX). When the experiments were conducted at 24 degrees C, the cytosolic calcium levels generally returned close to pre-stimulus baseline levels after washout. In contrast, when the working temperature was slightly raised (to 27 degrees C), complex secondary calcium rises were observed not only during prolonged stimulation, but also after short agonist application. The calcium modulation might be correlated with some form of cellular "learning" in the embryonic brain. Under particular conditions, where the regulation processes are either switched off by cell programmes or simply overloaded, the cascade of events comprising secondary calcium rises may lead to cell death.

Usefulness of thyrotropin-releasing hormone test, SMS 201-995, and bromocriptine in the diagnosis and treatment of gonadotropin-secreting pituitary adenomas

Five patients with gonadotropin-secreting pituitary adenomas were studied. The utility of gonadotropin response to TRH stimulation in the diagnosis and follow-up of these tumors was evaluated, as well as the effects of somatostatin analogue SMS 201-995 and bromocriptine on gonadotropin release. Three patients had FSH and LH secreting adenomas while the other two tumors secreted FSH and alpha-subunit. Transsphenoidal resection of the pituitary adenomas were performed in all patients. Following preoperative TRH administration (400 micrograms i.v.), marked increases were observed in FSH levels in two cases, in LH levels in three and in alpha-subunit in one. The FSH and LH responses to t.his stimulus persisted in the same patients after surgery. Following acute bromocriptine administration (5 mg orally), FSH was reduced in all cases by 19% to 46%, LH in three cases by 50-67% and alpha-subunit in one by 33%. In patient no. 5, with persistent high FSH levels in the immediate postoperative period, long-term bromocriptine treatment was administered (15 mg/d orally), resulting in normalization of FSH levels 6 months later, although the size of the tumor was not reduced. After acute SMS 201-995 administration (100 micrograms sc) FSH decreased in two cases by 38% and 76%, LH in three by 30-56% and alpha-subunit in one by 20%. We conclude that gonadotropin response to TRH stimulation is useful in the diagnosis and follow-up of patients with gonadotroph adenoma. Bromocriptine and SMS 201-995 may be effective as coadjuvant treatment following surgery and radiotherapy in these patients, although long-term studies will be necessary to confirm these proposals.

Gastric carcinoma: study of the most eminent prognostic factors

In order to analyse some prognostic factors in relation to gastric cancer, 218 patients were included in a prospective protocol at 'Hospital General de Elche' (Spain) with a follow-up of 100%. Survival curves were calculated using Kaplan-Meier analysis and compared using the log-rank test. The number of patients who underwent resection was 122 (63.5%). In 70 cases (36.5%) the resection was not possible. The postoperative mortality was 4.9%. In the survival of patients with gastric cancer we find the following prognostic factors are significant: age, tumour site, macroscopic type, depth of gastric wall affection, presence of lymph nodes, staging, resectability and surgical intention (curative vs palliative).

Hepatitis C antibody after kidney transplantation: clinical significance

The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 231 renal transplantation recipients, by a first- and second-generation EIA assay and a second-generation immunoblot assay (4-RIBA). Before transplantation, prevalence of anti-HCV was 22.6% and was related to the time on dialysis (p < 0.01), transfusions (p < 0.01) and previous history of chronic liver disease (p < 0.01. Following transplantation, 32 patients (13.9%) were anti-HCV positive by the first-generation enzyme immunoassay (EIA) and it increased to 57 patients (24.7%) when anti-HCV was measured by the second-generation EIA. The 4-RIBA assay confirmed the positivity in 46 patients (80.7%), 11 patients (19.3%) were indeterminate. Seroconversion after grafting was observed in 7 negative patients, and another 7 patients became negative after the procedure. The presence of anti-HCV antibody after transplantation was determined by the patient status on dialysis, 80% of them being positive before surgery. Twenty-one 4-RIBA-positive transplantation patients (45.7%) had persistently or intermittently abnormalities on liver function tests, suggesting chronic liver disease. A liver biopsy performed on 10 of these patients showed; chronic active hepatitis in 6, chronic persistent hepatitis in 2, and chronic lobular hepatitis in the other 2 patients. Another 23 4-RIBA-positive transplantation patients had normal alanine aminotransferase levels despite long follow-up (66.2 +/- 32.2 months). The prevalence of anti-HCV antibody can be underestimated if the antibody is measured by first-generation EIA alone. About 50% of patients with anti-HCV had chronic liver disease, and the histological findings suggested a possible evolution to cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[The use of a resorbable biological matrix in periodontal surgery: clinical observations of 230 cases]

The association of a biological glue and a biological dressing allowed to create a biologic resorbable matrix. The clinical study of numerous cases showed that the latter used dressing various periodontal surgeries minimized post surgical pain, favorised a better hemostasis and accelerated healing. The interaction between the various components of the biologic resorbable matrix seams to participate direct into the conjonctive healing process and ensure an active protection of surgical sites.

[Metabolic disorders in the gastrectomized patient]

The present study attempts on one hand to study the metabolic disorders which may present themselves in the gastrectomized patient, such as the malabsorption of fat, vitamin B12, folic acid and iron as well as the possible correlation between steatorrhea and the presence of exocrine pancreatic insufficiency. For this purpose a group of 71 patients have been studied who have undergone a subtotal gastrectomy (70.42%) or total (29.58%) in the General Surgery Services of Elche. The results obtained show the presence of ferropenic or megaloblastic anemia in 61.97% of the group, serious steatorrhea in only 3 patients (4.22%) and calciumphosphorous metabolism alterations appeared in 21.13%. With this we conclude that anemia is the most frequent ferropenic alteration in the gastrectomy patient; steatorrhea does not seem to be produced exclusively by the presence of exocrine pancreatic insufficiency and bone alterations in the gastrectomized patient appear in an insidious manner, being more a question of biochemical alterations than actual clinical lesions.

[Changes in aldosterone receptors in congestive heart disease. Report of a case]

It is presented a case with mitral and tricuspid rheumatic valvulopathy and refractory chronic congestive heart failure, which developed two episodes of severe hyponatremia and hyperkalemia, accompanied in at least one occasion of hyperpreninemia and hyperaldosteronism, after administration of 50 and 100 mg of sprionolactone for 2 and 3 weeks. It is believed that this severe effect of spironolactone was due to the presence of an alteration of aldosterone receptors acquired during the large period of congestive failure suffered by the patient. In as much as we have studied 4 similar cases in the last few months, a note of warning is done in the use of this drug in the treatment of this type of cardiac condition.

Empty sella and rhinorrhea. A report of eight treated cases

The association of an empty sella with rhinorrhea is an unusual finding. Of 29 cases of empty sella observed by the authors, eight underwent surgery for rhinorrhea. None of the patients showed clinical evidence of increased intracranial pressure or hydrocephalus. Seven were cases of primary empty sella, the eighth was an acromegalic patient, who had received radiotherapy 4 years before. Except for this patient, the others showed no clinical signs of a previous tumor. In the surgical treatment of these patients, the authors used both the transfrontal and transsphenoidal approaches. In spite of generally accepted good results following surgical closure of this type of fistula, four patients needed more than one operation. The fistula closed in only three of them; in the last patient rhinorrhea persisted after three operations.

[Aldosteronism after hypokalemia in diuretic therapy of systemic arterial hypertension]

Twenty-two cases with essential arterial hypertension were studied in the final part of a chronic period of treatment with Chlortalidona and in the first 30 days after treatment. Measurements of the following parameters were made: 1) Change in the excretion of urinary aldosterone (aldo). 2) Change in the arterial pressure (delta P). 3) Transtherapeutic serum potassium (delta K). 4) Change in the Q-T (delta QT) in the electrocardiogram. The measurements were made 3 days after the suppression of the drug and afterwards every 3 to 6 days for a month. The correlation of the K and QT was significant (r = 0.63). The P did not correlate with the K nor with the aldo (r = 0.14). The aldo was -5.92 +/- 3.1 ug./24 hs (p = 0.01) in those cases responsive to the drug. The disappearance of the antihypertensive effect occurred at 9.61 +/- 3.7 days and correlated with the normalization of the QT (r = 0.83) and the serum potassium. The delta aldo correlated with K (r = 0.56) and normalized 6.7 days after the suspension of the drug. The secondary aldosteronism participates in the parogenia of the transtherapeutic hypokalemia although with a slightly significant correlation. The important correlation between the disappearances of the antihypertensive effects and the electrocardiographic signs of hypokalemia may dwell in changes which directly or indirectly exercise the diuretic in the intracellular metabolism of K without necessarily cousing an antihypertensive effect additive of the same hypokalemia.

[Effect of alpha, beta blocker, labetol on the angiotensin renin system in arterial hypertension]

The effect of labetalol, a new alpha and beta adrenergic blocker, on blood pressure, heart rate, plasma renin activity (PRA), and urinary aldosterone excretion was assessed in 23 essential hypertensive patients, divided in 2 subgroups: 11 with normal electrocardiogram and 12 with left ventricular hypertrophy (LVH). In the first subgroup significant differences were found in the arithmethyc mean for sistolic blood pressure in sitting position (control: 166.1 +/- 17.2 mm of Hg treatment: 153.9 +/- 13.8, p less than or equal to 0.005) and in standing position (control: 165.3 +/- 17.3, treatment: 152.8 +/- 13.8, p less than or equal to 0.005) and for diastolic blood pressure (control: 102.7 +/- 12.6 to 89.9 +/- 10.1, p less than or equal to 0.001 and 103.2 +/- 11.8 to 91.2 +/- 10.8, p less than or equal to 0.001; in sitting and orthostatic positions, respectively.). No significant differences were found in the group with LVH. Heart rate decreased in the total population during treatment (- 6.0 +/- 7.5, p less than or equal to 0.05 and - 5.4 +/- 7.5 beats per minute, p less than or equal to 0.05 in sitting and orthostatic positions, respectively. PRA diminished in 12 of 15 cases studied (- 2.5 +/- 4.65 ng/ml/hr., p greater than 0.5). Correlation coefficient between decrements of diastolic blood pressure (sitting position) and ARP was 0.637. Aldosterone decreased in a non significant way during treatment. These data support the thesis of an important role of the adrenergic system in the pathogenesis of non complicated essential hypertension and, therefore, simultaneous alpha and beta receptor blockade in these cases has a better therapeutic effect. The good correlation between the decrements of ARP and blood pressure suggests an intervention of the inhibition of renin angiotensine system, brought about by the blocker property of labetalol, in the antihypertensive mechanism of the drug.

[Double-blind therapeutic trial of spironolactone in arterial hypertension]

Spironolactone is a diuretic, selective aldosterone, antagonist with its own antihypertensive action which prevents body loss of potassium. Its clinical use has been documented on the treatment of essential arterial hypertension; however, there does not seem to be enough information to form a solid chemical criterion. This work is a clinical evaluation of the antihypertensive effect of the drug using double-blind technic with 41 patients with essential arterial hypertension, all external patients from the Instituto de Cardiología. They were divided in two groups, selected at random, to be able to observe their tensional range with spironolactone every two weeks, during 16 weeks; and using a placebo for the next 16 weeks. On group following this order; and the other one viceversa. After 32 weeks, the results observed show the effect of placebo, as well as spironolactone on arterial pressure and the statistic comparison, states the real antihypertensive effect of the drug on this group of patients. Every day doses were from 300 to 450 mg., and with it there was a rise in seric potassium of an average of 1 mEq/l. The authors suggest that this drug is useful in cases of essential hypertension although its pathway isn't deeply known. Apparently, the antihypertensive effect of spironolactone is not solely on patients with hypertension due to primary aldosteronism. The intervention on various hipertensinogenous factors in relation to its effect are discussed.