Effect of preoperative inspiratory muscle training on physical functioning following esophagectomy

This study aims to examine the effect of preoperative inspiratory muscle training (IMT) on pre- and postoperative functional exercise performance in patients undergoing esophagectomy. A subcohort of patients recruited to the PREPARE randomized control trial were studied. Following evaluation of respiratory muscle function (spirometry, maximum inspiratory pressure (MIP), and inspiratory muscle endurance), postoperative mobilization (accelerometry) and postoperative physical functioning (6-minute walk test (6MWT)), participants scheduled for esophagectomy were randomly assigned to either 2 weeks of preoperative IMT or a control group. Measures were repeated on the day before surgery and postoperatively. Sixty participants (mean (standard deviation) age 64.13 (7.8) years; n = 42 male; n = 43 transthoracic esophagectomy; n = 17 transhiatial esophagectomy) were included in the final analysis (n = 28 IMT; n = 32 control). There was a significant improvement in preoperative MIP (P = 0.03) and inspiratory muscle endurance (P = 0.04); however preoperative 6MWT distance did not change. Postoperatively, control participants were more active on postoperative day (POD)1, and from POD1-POD5 (P = 0.04). Predischarge, 6MWT distance was significantly lower in the IMT group (305.61 (116.3) m) compared to controls (380.2 (47.1) m, P = 0.03). Despite an increase in preoperative respiratory muscle function, preoperative IMT does not improve pre- or postoperative physical functioning or postoperative mobilization following esophagectomy.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team

BACKGROUND/OBJECTIVES

Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST.

SUBJECTS/METHODS

All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied.

RESULTS

In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001).

CONCLUSIONS

Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

Prevention is better than cure

The vast majority of gastric cancers are sporadic. However, 1-3% arise as a result of inherited gastric cancer predisposition syndromes, generally referred to as hereditary diffuse gastric cancer (HDGC). Of those families that fulfill the clinical criteria for HGDC only 25% have a CDH1 germline mutation. No reliable surveillance technique exists for individuals with HDGC. Difficult decisions have therefore to be made by mutation carriers to proceed with prophylactic total gastrectomy, or undergo lifelong annual surveillance. We present a case of the management of a patient with a documented CDH1 mutation and briefly review the available literature.

ASPHALTENE CHARACTERISATION USING SPECTRAL ANALYSIS SYSTEM

Asphaltenes are the heaviest hydrocarbon component of crude oil and remain in colloidal suspension under reservoir temperature and pressure conditions. These materials may flocculate and deposit as a result of pressure, temperature and compositional changes, and consequently, disrupt production operations. This disruption can have severe implications, particularly in an offshore subsea environment. In these circumstances, it is imperative to understand the fundamental behaviour of asphaltenes prior to the development phase of any field under consideration.In this paper, we present a novel methodology to understand the thermodynamic asphaltene instability conditions using near infrared and spectral analysis system (SAS) techniques. Using the SAS technique, we were able to estimate the asphaltene particle size and growth behaviour as functions of pressure and time. Asphaltene particle size determined at the onset of asphaltene flocculation is in the order of 0.25 μm for a pressure-compensated sample. On the other hand, the asphaltene particle size is determined to be about 0.8 μm at the onset pressure using a conventional sample. Results also indicate that the particles from the pressure-compensated sample had a slower initial growth rate compared to the particles growth rate estimated from the non-pressure compensated sample. These results demonstrate the importance of representative sampling on asphaltene characterisation.

Clinical features of amyotrophic lateral sclerosis according to the El Escorial and Airlie House diagnostic criteria: A population-based study

BACKGROUND

The El Escorial and the revised Airlie House diagnostic criteria for amyotrophic lateral sclerosis (ALS) classify patients into categories reflecting different levels of diagnostic certainty. We conducted a prospective, population-based study of the natural course of ALS in the Republic of Ireland during a 6-year period to examine the utility of these ALS diagnostic criteria.

METHODS

Using data from the Irish ALS Register, we studied the clinical features of all patients diagnosed as having ALS in Ireland throughout their illness.

RESULTS

Between 1993 and 1998, 388 patients were diagnosed as having ALS. Forty percent of patients reported bulbar-onset symptoms. Disease progression occurred over time: at last follow-up, 75% of all patients had bulbar signs, compared with 59% at diagnosis. When the El Escorial criteria were applied, more than half of patients (218 [56%]) had definite or probable ALS at diagnosis. Of the 165 possible and suspected ALS cases at diagnosis (trial ineligible), 110 (67%) were trial eligible at last follow-up. Of the 254 patients who had died, 229 (90%) had definite or probable ALS, whereas 25 patients (10%) remained trial ineligible at death. El Escorial category at diagnosis was not a significant prognostic indicator. Use of the Airlie House criteria had no effect on the median time from symptom onset to trial eligibility (12.9 vs 12.8 months).

CONCLUSIONS

The El Escorial and Airlie House diagnostic criteria are excessively restrictive. Furthermore, levels of diagnostic certainty cannot be used as prognostic indicators. Arch Neurol. 2000;57:1171-1176

Amyotrophic lateral sclerosis mimic syndromes: a population-based study

BACKGROUND

The Irish ALS Register is a population-based register of the epidemiological characteristics of amyotrophic lateral sclerosis (ALS) in the republic of Ireland.

OBJECTIVE

To describe the clinical and demographic details of those patients included in the Irish ALS Register who were incorrectly diagnosed as having ALS (patients who were ultimately rediagnosed as having an "ALS mimic syndrome").

METHODS

The medical records of each patient referred to the register are routinely reviewed and, where possible, patients are examined by our group during their illness.

RESULTS

Between January 1, 1993, and December 31, 1997, 32 patients (representing 7.3% of 437 referrals) were rediagnosed as having a condition other than ALS. The median age at onset for these 32 patients was 56.0 years (range, 19.5-85.8 years) for men and 53.5 years (range, 39.5-70.4 years) for women. Twenty-nine patients (91%) presented with symptoms referable to the limbs, and the remainder presented with symptoms involving the bulbar musculature. Multifocal motor neuropathy was the most common condition mistaken for ALS, accounting for 7 cases (22%), followed closely by Kennedy disease (4 cases [13%]). Factors leading to diagnostic revision included evolution of atypical symptoms, results of specific investigations, and failure of symptoms to progress. Twenty-seven (84%) of the patients with an ALS mimic syndrome fulfilled the El Escorial criteria for either "suspected" or "possible" ALS, 4 (13%) met the criteria for probable ALS, and 1 (3%) had definite ALS.

CONCLUSIONS

The application of the El Escorial diagnostic criteria may facilitate early recognition of non-ALS cases. Misdiagnosis of ALS remains a common clinical problem despite the increased availability of investigations and a greater awareness among neurologists of potential diagnostic pitfalls.

Incidence and prevalence of ALS in Ireland, 1995-1997: a population-based study

BACKGROUND

We conducted a prospective, population-based study of ALS in the Republic of Ireland for the 3-year period 1995 to 1997.

METHODS

To ensure complete case ascertainment, multiple sources of information were used, including consultant neurologists, neurophysiologists, primary care physicians, and the Irish Motor Neuron Disease Association. The El Escorial diagnostic criteria for ALS were applied to all cases enrolled on the register and each patient was regularly followed up during his or her illness.

RESULTS

Between January 1, 1995, and December 31, 1997, 231 patients were diagnosed with possible, probable, or definite ALS, including 133 men (57.6%) and 98 women (42.4%). The average annual incidence rate was 2.1 per 100,000 person-years (95% CI, 1.8 to 2.4), and 2.8 per 100,000 person-years for the population older than 15 years (95% CI, 2.4 to 3.1). The incidence rate was higher for men, being 2.5 per 100,000 person-years (95% CI, 2.0 to 2.9), than for women, at 1.8 per 100,000 person-years (95% CI, 1.5 to 2.2), and increased with age for both sexes. The median age at onset was 64.2 years for men and 67.8 years for women. On December 31, 1996, the crude prevalence was 4.7 per 100,000 of the total population (95% CI, 4.0 to 5.5), and 6.2 per 100,000 for the population older than 15 years (95% CI, 5.3 to 7.1). Adjusting to the 1996 Irish population as standard, the incidence of ALS in Ireland during the 3-year study period is the third highest reported to date.

CONCLUSIONS

There was a trend toward a higher incidence of ALS in the northwestern region of Ireland, although the numbers of cases involved were small and further study is required.

Modified rosette inhibition test with mouse lymphocytes for detection of early pregnancy factor in human pregnancy serum

The rosette inhibition test has been modified so that early pregnancy factor (EPF) in human pregnancy serum can be detected with mouse lymphocytes. Interference with the assay, which would result from incubation of lymphocytes with heterologous serum proteins, is prevented by the introduction of an ion exchange chromatography step. This provides a simple and rapid method for separating EPF from interfering serum proteins. Human pregnancy and non-pregnancy sera were assayed for EPF with human lymphocytes and results compared with those obtained with DEAE-Sephacel fractions of the same sera tested with mouse lymphocytes. The 2 systems showed good agreement but the mouse assay gave greater differentiation between positive and negative results. When monoclonal anti-T cell antibodies, Hu Ly-m1 and anti-Ly-1.1, were substituted for anti-lymphocyte sera in the human and mouse assay systems respectively, similar results were obtained. The mouse assay system has several advantages over the human assay, including stability of the anti-mouse lymphocyte serum and the ready availability of mouse lymphocytes. Moreover the modified method may be applied not only to the assay of human EPF, but also to the assay of EPF from other species. This would be of value if several species were being studied in 1 laboratory, or if sufficient quantities of lymphocytes from a particular species were not available.