Gastro-esophageal reflux successfully treated with transgastrostomal jejunal tube feeding

1. The release of endogenous gamma-aminobutyric acid (GABA) and glutamic acid in the human brain has been investigated in synaptosomal preparations from fresh neocortical samples obtained from patients undergoing neurosurgery to reach deeply located tumours. 2. The basal outflows of GABA and glutamate from superfused synaptosomes were largely increased during depolarization with 15 mM KCl. The K(+)-evoked overflows of both amino acids were almost totally dependent on the presence of Ca(2+) in the superfusion medium. 3. The GABAB receptor agonist (-)-baclofen (1, 3 or 10 microM) inhibited the overflows of GABA and glutamate in a concentration-dependent manner. The inhibition caused by 10 microM of the agonist ranged from 45-50%. 5. The effect of three selective GABAB receptor antagonists on the inhibition of the K(+)-evoked GABA and glutamate overflows elicited by 10 microM (-)-baclofen was investigated. Phaclofen antagonized (by about 50% at 100 microM; almost totally at 300 microM) the effect of (-)-baclofen on GABA overflow but did not modify the inhibition of glutamate release. The effect of (-)-baclofen on the K(+)-evoked GABA overflow was unaffected by 3-amino-propyl (diethoxymethyl)phosphinic acid (CGP 35348; 10 or 100 microM); however, CGP 35348 (10 or 100 microM) antagonized (-)-baclofen (complete blockade at 100 microM) at the heteroreceptors on glutamatergic terminals. Finally, [3-[[(3,4-dichlorophenyl) methyl]amino]propyl] (diethoxymethyl) phosphinic aid (CGP 52432), 1 microM, blocked the GABAB autoreceptor, but was ineffective at the heteroreceptors. The selectivity of CGP 52423 was lost at 30 microM, as the compound, at this concentration, inhibited completely the (-)-baclofen effect on both GABA and glutamate release. 5. It is concluded that GABA and glutamate release evoked by depolarization of human neocortex nerve terminals can be affected differentially through pharmacologically distinct GABAB receptors.     

Aseptic sialadenitis in preterm infants associated with long-term oro-gastric tube feeding

Sialadenitis is a rare disease in the newborn and the pathogenesis in this age group is not fully understood. We report five cases of neonatal sialadenitis in stable preterm, gavage-fed infants at 2 to 6 weeks postnatal age. The occurrence of sialadenitis was observed in temporal relation to changes in enteral feeding routines in the unit which were initiated with the objective of promoting full breast feeding at discharge. Clinical presentation consisted of a tender palpable mass over one of the salivary glands, low-grade (37.5-38.3 degrees C) fever in conjunction with clinical malaise. C-reactive protein and white blood cell count were only moderately elevated. No suppuration from salivary ducts was present. Bacterial cultures were invariably negative. Viral investigations were not carried out. Aseptic sialadenitis was suggested as the cause of the symptoms. The clinical course was benign and the local tender mass over the salivary gland vanished shortly after intravenous fluids and antibiotics were started. CONCLUSION: Long-term exclusive oro-gastric feeding may result in reduced reflex salivary gland stimulation, saliva production and hence ductal clearance of mucoid saliva, leading to functional ductal obstruction and local inflammation.     

Feeding tubes for tube feeding

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.     

Dermatomyositis associated with fallopian tube carcinoma

Dermatomyositis (DM) is an idiopathic inflammatory myopathy associated with characteristic cutaneous and extracutaneous manifestations, including malignancy. Primary fallopian tube carcinoma (FTC) is the least common site of origin for a malignant neoplasm of the female genital tract. This report describes the first documented case of DM and concurrent FTC in the United States. A 62-year-old woman presented with DM and was subsequently found to have FTC. During her clinical course, she had improvement in strength and function with treatment of the underlying FTC, which also correlated with lower creatinine phosphokinase levels. An association between DM and FTC may exist because of significant functional strength improvements after tumor removal and chemotherapy.     

Enteral tube feeding in a patient with traumatic brain injury

Tube feeding is frequently needed for patients with severe traumatic brain injury. When the patient is on the rehabilitation unit, bolus type feeding by gastrostomy tube is more easily accomplished than continuous type feeding by jejunostomy tube (J-tube). In the case presented here, the patient received less calories via J-tube feeds while he was on the rehabilitation unit than when he was in the intensive care unit or the neurosurgical unit. This has implications for the trauma team, which initially decides the type of nutritional support.     

Simplified insertion of a transpyloric feeding tube

Placement of a transpyloric feeding tube is a common procedure done through a previous gastrostomy site. Conventional fluoroscopic and endoscopic methods can be tedious because of the difficulty in cannulating the pylorus. Described here is a simplified method to place a transpyloric feeding tube under fluoroscopy.     

Nonradiographic assessment of enteral feeding tube position

OBJECTIVE: To determine whether a clinical, nonradiographic criterion can be used to predict when the tip of a blindly placed feeding tube is in the small intestine. DESIGN: Prospective sample. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Critically ill children requiring transpyloric feeding. INTERVENTIONS: The small bowel was intubated, using a blind, bedside transpyloric feeding tube placement protocol. The feeding tube was considered to be in the small bowel when <2 mL of a 10- mL aliquot of insufflated air could be aspirated from the feeding tube. This clinical criterion was confirmed with an abdominal radiograph. MEASUREMENTS AND MAIN RESULTS: Patient age ranged from 1 month to 19 yrs (median 6 months). Weight ranged from 2.2 to 60 kg (median 4.9). Median time to feeding tube placement was 10 mins (range 5 to 60). Eighty-nine percent of the patients were mechanically ventilated, while 28% of these patients were pharmacologically paralyzed. Seventy-five feeding tubes were inserted. There were no known complications. Ninety-nine (74/75) percent of the feeding tubes were positioned in the small bowel. The inability to aspirate insufflated air correctly predicted small bowel intubation with 99% certainty (Sequential Probability Ratio Test, p = .05 and power = .80). This test incorrectly predicted the position of only one feeding tube, the 26th, which was in the stomach. Of the 74 feeding tubes positioned in the small bowel, 13 feeding tubes were in the duodenum and 61 were in the jejunum. CONCLUSIONS: The inability to aspirate insufflated air confirms the transpyloric position of a feeding tube. Other clinical criteria did not successfully predict small bowel intubation. Use of this single test may obviate confirmatory abdominal radiographs in carefully selected patients and may lead to more cost-effective and timely initiation of enteral feedings.     

Enteral tube feeding of small animals in practice: nasoesophageal tube and percutaneous gastrostomy tube

Enteral force feeding via a feeding tube is a widely accepted, but rarely used technique in practice. Two simple methods are discussed: the nasoesophageal tube, which can be positioned quickly without the need of general anaesthesia for diseases of predictably short duration and the percutaneous gastrostomy tube, which is placed blindly under short general anaesthesia without endoscopic or surgical procedures and which is designed for month long force feeding.     

A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition

RATIONALE AND OBJECTIVES: A survey of chief residents of academic radiology programs is conducted annually on behalf of the American Association of Academic Chief Residents in Radiology (A3CR2). Data are obtained to improve the training of diagnostic radiology residents and to increase the understanding of radiologists and their associates about issues of interest to radiologists in training. METHODS: Questionnaires were mailed to 133 accredited programs in the United States and Canada. A wide variety of demographic and common interest questions were asked. The analysis took into account geographic location of the responders and the size of the residency program. Comparisons were made to the data from prior years. RESULTS: Completed surveys from 93 programs (70%) were returned. The percentage of women residents is increasing. Important regional and size variations exist in several areas including salary, workload, prior clinical training, resident/fellow ratios, post residency plans, and call schedules. Although many chief residents feel knowledgeable about the health care system, opinions about the future of radiology and medical care are tentative. CONCLUSIONS: This survey provides important demographic information about academic radiology residency programs. The summary information regarding plans for fellowship training, resident call schedules, and opinions about socioeconomic issues may be useful for chief residents, program directors, and departmental chairmen.     

Surgical management of rectal and jejunal tears associated with dystocia in a cow

The rectal and jejunal tears associated with dystocia in a cow were treated surgically. The cow developed peritonitis which was treated medically. It recovered, was successfully rebred and delivered a live calf.     

Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery

Intraluminal incision is often used for the treatment of strictures of both the upper and the lower urinary tracts. The depth of the stricture and the location of surrounding structures such as blood vessels are important factors in guiding the incision. Endoluminal ultrasonography has been shown to be effective in defining periureteral anatomy accurately. A new device is described that combines an endoluminal ultrasound transducer and cutting device (electrocautery or laser fiber) in 9F catheter. This catheter was evaluated in two live anesthetized pigs (four kidneys) and four ex-vivo kidneys. Incisions were made at the ureteropelvic junction and middle and distal ureter. The ability to image the periureteral structures and to direct the location and the adequacy of the incision were assessed. Endoluminal ultrasound imaging was excellent, and the electrocautery wire was well seen. Well-defined, limited, full-thickness incisions were made using this device and could be directed accurately toward or away from periureteral vessels. This study demonstrates the potential for endoluminal ultrasound guidance of intraluminal incisions.     

Decisions about enteral tube feeding among the elderly

OBJECTIVE: To characterize the acute actions and physiologic dose profile of epinephrine, as a single inotrope, in patients with septic shock. DESIGN: Prospective clinical study. The relationship between epinephrine dose and cardiovascular variables was analyzed using repeated-measures analysis of variance. SETTING: ICU in a university teaching hospital. PATIENTS: Eighteen patients with septic shock, mean age 64 +/- 8 (SD) yrs, and with a mean admission Acute Physiology and Chronic Health Evaluation (APACHE II) score of 23 (range 14 to 35). INTERVENTIONS: Initial volume loading and the measurement of a baseline hemodynamic profile were followed by the administration of an epinephrine infusion at 3 microgram/min with subsequent increments of 3 micrograms/min and the determination of a hemodynamic profile after each dose increment. Therapy was titrated to clinical goals of perfusion and restoration of premorbid systolic arterial BP. MEASUREMENTS AND MAIN RESULTS: After volume loading, mean hemodynamic indices were as follows: mean arterial pressure (MAP) 62 +/- 7 mm Hg; cardiac index 3.8 +/- 1.1 L/min/m2; left ventricular stroke work index 25 +/- 11 g.m/m2; oxygen delivery (Do2) index 460 +/- 168 mL/min/m2; and oxygen consumption (VO2) index 165 +/- 64 mL/min/m2. In the dose range of 3 to 18 microgram/min, epinephrine produced linear increases in average heart rate, MAP, cardiac index, left ventricular stroke work index, stroke volume index, VO2, and DO2. No effect was noted on pulmonary artery occlusion pressure (PAOP), mean pulmonary arterial pressure, or systemic vascular resistance index. CONCLUSIONS: Epinephrine increases DO2 in septic shock by increasing cardiac index without an effect on systemic vascular resistance index or PAOP.     

Intramedullary fat necrosis of multiple bones associated with pancreatitis

We describe findings of intramedullary fat necrosis on five imaging studies in a patient with alcoholic pancreatitis. Radiography and CT of extremities showed multiple osteolytic lesions that were initially considered to be metastases. However, a 99mTc-methylene diphosphonate whole-body bone scan revealed abnormal areas of increased uptake in only the bones of extremities without involvement of the axial skeleton, a distribution quite unusual for metastatic disease. Furthermore, 99mTc-sestamibi scintigraphy was essentially normal. MRI revealed findings compatible with the diagnosis of fat necrosis/infarct. Findings from bone biopsy demonstrated necrotic bone marrow without malignant cells. It may not be necessary to perform all the imaging studies described in this report when clinical features suggesting metastatic fat necrosis are present. Appearance and distribution of abnormalities on the whole-body bone scan and MR images show that necrosis/infarct of the marrow may obviate bone biopsy, which is often needed to confirm the diagnosis of intramedullary fat necrosis and to exclude neoplastic processes.     

Case 4: intraosseous fat necrosis associated with pancreatitis

The cDNA for human cytosolic asparaginyl-tRNA synthetase (hsAsnRSc) has been cloned and sequenced. The 1874 bp cDNA contains an open reading frame encoding 548 amino acids with a predicted M r of 62 938. The protein sequence has 58 and 53% identity with the homologous enzymes from Brugia malayi and Saccharomyces cerevisiae respectively. The human enzyme was expressed in Escherichia coli as a fusion protein with an N-terminal 4 kDa calmodulin-binding peptide. A bacterial extract containing the fusion protein catalyzed the aminoacylation reaction of S.cerevisiae tRNA with [14C]asparagine at a 20-fold efficiency level above the control value confirming that this cDNA encodes a human AsnRS. The affinity chromatography purified fusion protein efficiently aminoacylated unfractionated calf liver and yeast tRNA but not E.coli tRNA, suggesting that the recombinant protein is the cytosolic AsnRS. Several human anti-synthetase sera were tested for their ability to neutralize hsAsnRSc activity. A human autoimmune serum (anti-KS) neutralized hsAsnRSc activity and this reaction was confirmed by western blot analysis. The human asparaginyl-tRNA synthetase appears to be like the alanyl- and histidyl-tRNA synthetases another example of a human Class II aminoacyl-tRNA synthetase involved in autoimmune reactions.     

Cutaneous necrosis associated with acquired severe protein S deficiency

The incidence of benign lymphoepithelial lesions of the parotid gland in patients afflicted with HIV has increased. Enucleation is a safe and effective procedure that provides the patient with complete removal of the cyst and a low recurrence rate. Enucleation of these parotid cysts should be considered in treating these patients.