Early versus late tube feeding initiation after PEG tube placement: Does time to feeding matter?

BACKGROUND

Variation exists in the timing of tube feed initiation after percutaneous endoscopic gastrostomy (PEG) tube placement. The aim of our study was to review outcomes of early tube feed (ETF) versus late tube feed (LTF) initiation after PEG tube placement.

METHODS

We performed a retrospective review of all trauma patients who underwent PEG tube placement from 1/2014 to 12/2018. ETF was defined as initiation < 24 h and LTF > 24 h after placement. The primary outcome measure was feeding intolerance and secondary outcomes included post-operative complications. All statistical analyses were performed using standard statistical methods (e.g. Pearson's Chi-squared, Fisher's exact and Mann Whitney-U tests).

RESULTS

There were 295 patients (164 ETF and 131 LTF) that received a PEG tube at our level 1 trauma center. There was no difference with feeding intolerance at 12 h (5% vs. 4%; p = 0.88), 24 h (1% vs. 2%; p = 1.00), and 48 h (4% vs. 4%; p = 1.00). There was no difference when comparing intolerance symptoms such as nausea and vomiting (1% vs. 2%; p = 0.79), abdominal tenderness (2% vs. 3%; p = 0.76), high gastric residuals (2% vs. 2%; p = 1.00) and aspiration (0% vs. 2%; p = 0.39). There was no difference when comparing post-operative complications (4% vs. 8%; p = 0.21).

CONCLUSIONS

Early tube feeding after PEG placement is safe and equivalent to late tube feeding in the adult trauma population. Future prospective studies are warranted to establish the optimal timing for initiation of tube feeds after PEG tube placement.

A porous circulation model of the human brain for in silico clinical trials in ischaemic stroke

The advancement of ischaemic stroke treatment relies on resource-intensive experiments and clinical trials. In order to improve ischaemic stroke treatments, such as thrombolysis and thrombectomy, we target the development of computational tools for in silico trials which can partially replace these animal and human experiments with fast simulations. This study proposes a model that will serve as part of a predictive unit within an in silico clinical trial estimating patient outcome as a function of treatment. In particular, the present work aims at the development and evaluation of an organ-scale microcirculation model of the human brain for perfusion prediction. The model relies on a three-compartment porous continuum approach. Firstly, a fast and robust method is established to compute the anisotropic permeability tensors representing arterioles and venules. Secondly, vessel encoded arterial spin labelling magnetic resonance imaging and clustering are employed to create an anatomically accurate mapping between the microcirculation and large arteries by identifying superficial perfusion territories. Thirdly, the parameter space of the problem is reduced by analysing the governing equations and experimental data. Fourthly, a parameter optimization is conducted. Finally, simulations are performed with the tuned model to obtain perfusion maps corresponding to an open and an occluded (ischaemic stroke) scenario. The perfusion map in the occluded vessel scenario shows promising qualitative agreement with computed tomography images of a patient with ischaemic stroke caused by large vessel occlusion. The results highlight that in the case of vessel occlusion (i) identifying perfusion territories is essential to capture the location and extent of underperfused regions and (ii) anisotropic permeability tensors are required to give quantitatively realistic estimation of perfusion change. In the future, the model will be thoroughly validated against experiments.

A new fibre optic pulse oximeter probe for monitoring splanchnic organ arterial blood oxygen saturation

A new, continuous method of monitoring splanchnic organ oxygen saturation (SpO(2)) would make the early detection of inadequate tissue oxygenation feasible, reducing the risk of hypoperfusion, severe ischaemia, and, ultimately, death. In an attempt to provide such a device, a new fibre optic based reflectance pulse oximeter probe and processing system were developed followed by an in vivo evaluation of the technology on seventeen patients undergoing elective laparotomy. Photoplethysmographic (PPG) signals of good quality and high signal-to-noise ratio were obtained from the small bowel, large bowel, liver and stomach. Simultaneous peripheral PPG signals from the finger were also obtained for comparison purposes. Analysis of the amplitudes of all acquired PPG signals indicated much larger amplitudes for those signals obtained from splanchnic organs than those obtained from the finger. Estimated SpO(2) values for splanchnic organs showed good agreement with those obtained from the finger fibre optic probe and those obtained from a commercial device. These preliminary results suggest that a miniaturized 'indwelling' fibre optic sensor may be a suitable method for pre-operative and post-operative evaluation of splanchnic organ SpO(2) and their health.

Preliminary assessment of abdominal organ perfusion utilizing a fiber optic photoplethysmographic sensor

In an attempt to overcome the limitations of current techniques for monitoring abdominal organ perfusion, a prototype reflectance fiber optic photoplethysmographic (PPG) sensor and processing system was evaluated on seventeen anaesthetized patients undergoing laparotomy. Good quality PPG signals were obtained from the large bowel, small bowel, liver and stomach. Simultaneous PPG signals from the finger were also obtained for comparison purposes using an identical fiber optic sensor. Analysis of the mean ac and dc PPG amplitudes of all acquired signals indicated larger amplitudes for those signals obtained from abdominal organs than those obtained from the finger. Mean estimated blood oxygen saturation (SpO(2)) values from all abdominal sites showed good agreement with those obtained from the finger using both the finger fiber optic sensor and a commercial finger pulse oximeter. Furthermore, a Bland and Altman between-method-differences analysis on the estimated SpO(2) data suggests that a fiber optic abdominal sensor may be a suitable method for the evaluation of abdominal organ perfusion.

In-vivo evaluation of a fiber-optic splanchnic photoplethysmographic sensor during open laparotomy

There is a need for a reliable and continuous monitoring of abdominal organ oxygen saturation (SpO(2)). Splanchnic ischemia may ultimately lead to cellular hypoxia and necrosis and may well contribute to the development of multiple organ failures and increased mortality. A new prototype reflectance fiber optic photoplethysmographic sensor and signal processing system was evaluated on six anaesthetized patients undergoing elective laparotomy. PPG signals were obtained from various organs, including large and small bowel, liver, and stomach. The normalized amplitudes of the splanchnic PPG signals were in good agreement with those obtained from the periphery using an identical fiber optic sensor. Furthermore, average SpO(2) values were in good agreement and showed correlation with those obtained from a commercial system. These preliminary results suggest that a miniaturized 'indwelling' fiber optic sensor may be a suitable method for pre-operative and post-operative evaluation of splanchnic organ SpO(2) and their health.

Chronotherapy in traditional Chinese medicine

The circadian rhythm of illness has been emphasized for thousands of years in Traditional Chinese Medicine (TCM), using this knowledge to schedule therapies such as acupuncture during appropriate hours of the day. This paper reviews the time periods (two hour segments) that apply to each organ system according to TCM (lungs, large intestine, stomach, heart, kidneys and liver), and elaborates on how recent medical research has found similar relevant biorhythms in these very same organ systems.

Attitudes towards anti-smoking legislation in Israel: a Jerusalem study

BACKGROUND

With smoking on the rise among teenagers, the United States has recently implemented anti-smoking legislation, though with questionable success.

OBJECTIVES

To examine the attitudes in Israel to such legislation.

METHODS

An interviewer-administered questionnaire was completed by 505 adults: 217 undergoing general employment checkups and 288 amateur athletes requiring medical testing for certification. Smoking habits and attitudes toward anti-smoking legislation were examined.

RESULTS

The overall rate of smoking was 25.3%, with a male:female ratio of 1:24 (P = 0.232). Most smokers (65.6%) started smoking before the age of 20, and only 47.7% tried to quit at least once. Both the smokers and the non-smokers who were interviewed were in favor of legislation that recognized cigarettes as an addictive substance, restricted the sale of cigarettes to people aged 18 and older, and banned cigarette advertisements.

CONCLUSIONS

Anti-smoking legislation is looked upon favorably by Israelis, though the true benefit of such measures is questionable. Priority must be given to primary prevention through education and empowering youth to choose not to smoke.

Pulmonary hypertension secondary to neurofibromatosis: intimal fibrosis versus thromboembolism

Neurofibromatosis has been known to involve blood vessels throughout the body. Pulmonary involvement with interstitial fibrosing alveolitis has been described but no case of pulmonary vascular involvement has been reported to date. A 51 year old patient with cutaneous neurofibromatosis is described who presented with severe pulmonary hypertension and radiographic, scintigraphic, and angiographic evidence of chronic thromboembolic pulmonary hypertension. Severe intimal fibrosis consistent with vascular involvement with neurofibromatosis was found on endarterectomy with no evidence of pulmonary thromboembolism. Neurofibromatosis of pulmonary arteries should be considered as a possible cause of pulmonary hypertension.

Smoking among hospital doctors in Israel and their attitudes regarding anti-smoking legislation

Anti-smoking legislation has been implemented in several countries. In order to study the attitudes of Israeli doctors to such legislation, 260 hospital doctors were questioned regarding their smoking habits and attitudes towards anti-smoking legislation. It was discovered that 15.8% are current smokers [40% of radiologists, 25% of surgeons and anesthetists, and 8% of internists and pediatricians (P = 0.0005)], of which 76% began smoking before the age of 20, and 54% tried to quit at least once. 24.2% of the current non-smokers are prior smokers who stopped, 92% of non-smokers and 83% of smokers tell their patients to quit (P = 0.10). 69% feel that cigarette sales should be limited to those of 18 y and older, 77% that advertisements for cigarettes should be prohibited, and 74% that nicotine should be recognized as an addictive substance. Doctors who smoke may have difficulty promoting healthy behavior among their patients. They must be offered help in order to quit, and emphasis should be placed on prevention among medical students.

Polyarteritis nodosa and drug abuse: is there a connection?

Drug abuse has been controversially linked to polyarteritis nodosa. A 28-year-old man with a history of drug abuse with inhaled heroin presented with an enigmatic illness consisting of refractory fever, bilateral pleural effusions, migratory polyarthritis, and a leukaemoid reaction. An abdominal angiography confirmed the diagnosis of polyarteritis nodosa, and treatment with both prednisone and cyclophosphamide resulted in significant clinical and laboratory improvement.

Sepsis stimulates nonlysosomal, energy-dependent proteolysis and increases ubiquitin mRNA levels in rat skeletal muscle

We tested the role of different intracellular proteolytic pathways in sepsis-induced muscle proteolysis. Sepsis was induced in rats by cecal ligation and puncture; controls were sham operated. Total and myofibrillar proteolysis was determined in incubated extensor digitorum longus muscles as release of tyrosine and 3-methylhistidine, respectively. Lysosomal proteolysis was assessed by using the lysosomotropic agents NH4Cl, chloroquine, leupeptin, and methylamine. Ca(2+)-dependent proteolysis was determined in the absence or presence of Ca2+ or by blocking the Ca(2+)-dependent proteases calpain I and II. Energy-dependent proteolysis was determined in muscles depleted of ATP by 2-deoxyglucose and 2.4-dinitrophenol. Muscle ubiquitin mRNA and the concentrations of free and conjugated ubiquitin were determined by Northern and Western blots, respectively, to assess the role of the ATP-ubiquitin-dependent proteolytic pathway. Total and myofibrillar protein breakdown was increased during sepsis by 50 and 440%, respectively. Lysosomal and Ca(2+)-dependent proteolysis was similar in control and septic rats. In contrast, energy-dependent total and myofibrillar protein breakdown was increased by 172% and more than fourfold, respectively, in septic muscle. Ubiquitin mRNA was increased severalfold in septic muscle. The results suggest that the increase in muscle proteolysis during sepsis is due to an increase in nonlysosomal energy-dependent protein breakdown, which may involve the ubiquitin system.