Percutaneous endoscopic gastrostomy (PEG) - a long-term follow-up study in head and neck cancer patients.

Many patients with head and neck cancer experience problems related to swallowing. A retrospective study of 156 consecutive patients who received a percutaneous endoscopic gastrostomy (PEG) at a teaching hospital is presented. The results showed that 42% had complications. Fatal complications were seen in connection with PEG tube placement, but severe and minor complications could occur much later. The method of PEG tube insertion did not affect the complication rates. The spectrum of observed complications is different to that reported earlier, suggesting that the learning curve of surgeons under training could have influenced the outcome. It may be concluded that for a very sick patient a theoretically easy surgical procedure could turn into a potentially dangerous operation. It is important to select suitable candidates for a PEG. Head and neck cancer patients with a PEG need special attention in connection with the PEG tube placement and also in a long perspective, e.g. by follow-up at a nurse-led outpatient clinic.

Allopurinol as prophylaxis against pouchitis following ileal pouch-anal anastomosis for ulcerative colitis. A randomized placebo-controlled double-blind study.

BACKGROUND: Pouchitis is the major long-term complication of restorative proctocolectomy for ulcerative colitis (UC). Allopurinol is a scavenger of oxygen-derived free radicals, which it is suggested play a role in the development of UC and pouchitis. The first aim was to test the hypothesis that the incidence of pouchitis can be reduced by prophylactic Allopurinol, and secondly to evaluate if Allopurinol influences the overall pouch function. METHODS: 273 patients with UC who were planned for proctocolectomy and ileal pouch-anal anastomosis at 12 centres in Sweden between October 1994 and June 1997 were offered the opportunity to participate. 184 patients (67%) were randomized to receive postoperative prophylactic Allopurinol 100 mg twice daily or placebo. All 273 patients had clinical and endoscopic follow-up at 1, 3, 6, 12, 18, 24 months after surgery. RESULTS: Of the 184 randomized patients, 94 were randomized to Allopurinol and 90 to placebo; 116 patients (63%) completed follow-up and the crude incidence of pouchitis among those patients fullfilling the protocol was 31% in the Allopurinol group and 28% in the placebo group (ns). The cumulative risk for a first attack of pouchitis was 30% and 26% after 24 months (ns). The overall pouch function improved over time and did not differ significantly between the two groups. CONCLUSIONS: Prophylactic Allopurinol did not reduce the risk of a first attack of pouchitis.

Predetermined chirality at metal centers of various coordination geometries: a chiral cleft ligand for tetrahedral (T-4), square-planar (SP-4), trigonal-bipyramidal (TB-5), square-pyramidal (SPY-5), and octahedral (OC-6) complexes

Two tetradentate bispinene-bipyridine type ligands, each with six stereogenic carbon centers, were synthesized from (-)-alpha-pinene. Their ability to predetermine chiral configurations at metal centers was studied. The two diastereoisomers, L1 and L2, differ in their absolute configuration at the bridgehead position. These ligands form metal complexes with Ag(I), Pd(II), Zn(II), Cu(II), and Cd(II), with coordination numbers four, five, and six and with complete control of chirality at the metal centers. Using L1 rather than L2 leads to complexes of inverted absolute configuration at the metal centers. These diastereomeric coordination species can be obtained either as separate compounds or, in some cases, as solids containing them in a 1:1 ratio. Ligands L1 and L2 thus show that the pinene-bipyridines are versatile molecules for the formation of metal complexes with predetermined chirality. In all cases, absolute configurations were determined in the solid state by X-ray diffraction methods and in solution by CD spectroscopy. The sign of exciton couplets from the pi-pi* transitions always agrees with the expectations for a given local configuration at the metal center. The five-coordinate, inherently chiral species of Zn(II) and Cu(II) described in this article are the first examples of trigonal-bipyramidal metal complexes with predetermined absolute configuration containing topologically linear ligands.

Local short-chain fatty acids supplementation without beneficial effect on inflammation in excluded rectum.

BACKGROUND: Rectal instillation of short-chain fatty acids (SCFA), important nutrients for the colorectal mucosa, has been suggested to be of therapeutic value in distal intestinal inflammation. METHODS: In this study nine patients with Hartmann-closed rectum after colectomy for acute colitis were investigated. In a double-blind crossover trial an enema containing SCFA or a placebo solution was administered twice daily for 3 weeks. Before entry into the protocol, after each treatment period, and 6 weeks after the study period the patients' symptoms were evaluated, rectal endoscopy was performed, histologic samples were scored, and microbiologic analyses were carried out. RESULTS: No significant differences in symptoms, in mucosal inflammation, in histologic scoring, or in microbiologic studies were found between SCFA and placebo periods. Unexpectedly, all but one patient entirely lacked coliform bacteria in the rectum. CONCLUSIONS: In this study SCFA enemas had no beneficial effect on inflammation in excluded rectum in patients earlier submitted to colectomy for colitis. However, a different rectal flora was detected in these patients.

Stereoselective Synthesis of Coordination Compounds: Self-Assembly of a Polymeric Double Helix with Controlled Chirality.

Its information content is infinitely smaller than that of DNA, but its structure (see picture) ressembles the double-stranded helix produced by nature. This self-assembled, configurationally predetermined coordination polymer is built up from enantiopure chiral bipyridine-type ligands and silver ions.

Increased protein synthesis after acute IGF-I or insulin infusion is localized to muscle in mice.

The purpose of the present study was to determine the effect of acute administration of insulin-like growth factor I (IGF-I) or insulin on in vivo protein synthesis in muscle and other organs in fasted mice and to compare this response with that produced by feeding. Recombinant IGF-I (3.3 nmol prime, 3.33 nmol/h) or insulin (0.056 nmol/h) was infused intravenously for 60 min along with glucose to prevent hypoglycemia. Fractional rates of tissue protein synthesis (FSR) were determined by injection of [2H5]phenylalanine (25 mg/100 g body wt, 40% enriched). Both IGF-I and insulin caused a 25% increase in FSR of heart (P < 0.001) and soleus muscle (P < 0. 05) and a 65% increase in gastrocnemius and plantaris muscle (both P < 0.001), thus restoring rates to those seen in fed animals. A fivefold lower dose of IGF-I also stimulated protein synthesis in gastrocnemius muscle and heart (both P < 0.05) but not in soleus muscle. No significant effects of IGF-I on FSR were detected in liver, kidney, spleen, proximal small intestine, colon, lung, or brain. The results indicate that the ability of an overnight fast to decrease protein synthesis and the acute effects of insulin and IGF-I to stimulate protein synthesis are restricted to skeletal and cardiac muscles.

Hormonal regulation of protein metabolism in relation to nutrition and disease.

This paper examines the role of hormones in the normal responses of muscle protein synthesis to nutrient intake and the use of hormones to improve the effects of nutritional therapies in patients with protein-wasting conditions. In growing rats, the increase in muscle protein synthesis after feeding seems to be mediated by the rise in plasma insulin and also by an enhanced sensitivity of the muscle to insulin brought about by the amino acid leucine. In adult rats, however, the responsiveness of muscle to both feeding and insulin is much reduced, suggesting that changes in protein degradation play an important role in the response to feeding. Similarly, in adult humans, muscle protein synthesis is not affected by insulin, but is stimulated by insulin-like growth factor (IGF)-I and growth hormone (GH). The effect of GH treatment has been studied in a number of different groups of patients suffering from protein wasting, and improvements in nitrogen balance and lean body mass have been reported. In a study of patients with acquired immunodeficiency syndrome (AIDS), however, GH treatment for 2 wk caused a fall in muscle protein synthesis in the patients with wasting, despite an increase in healthy controls, suggesting that the responsiveness of muscle to the hormone may be altered by the stage of the disease.

Bulking fibre prevents translocation to mesenteric lymph nodes of an efficiently translocating Escherichia coli strain in rats.

BACKGROUND: starvation for 24 h prior to experimental haemorrhage increases bacterial translocation in rats. Forty-eight hours starvation alone causes pronounced microbiological changes in caecal contents and a marked increase in bacterial adherence to caecal epithelium. The aim of the present study was to examine whether bulking fibre prevents these microbiological changes induced by starvation, i.e. mucosal adherence and/or bacterial translocation with and without haemorrhage in rats. METHODS: 32 rats were inoculated with the translocating Escherichia coli strain Kl-C1. Groups of these rats were then starved for 48 h with or without access to bulking fibre. An additional group of rats was given bulking fibre and subjected to haemorrhage. A control group was untreated and given regular food. Samples were taken from caecal contents, caecal epithelium, mesenteric lymph nodes and blood. A biochemical fingerprinting method was used to characterize and compare E. coli strains in all samples. RESULTS: ingestion of bulking fibre alone for 48 h significantly reduced the frequency of Kl-C1 both in caecal contents and on caecal epithelium and completely prevented translocation of the strain, compared to starvation without bulking fibre for 48 h. Enforced stress (haemorrhage) increased bacterial translocation to the same level as starvation for 48 h. E. coli phenotypes found in mesenteric lymph nodes were also found adhering to the caecal epithelium. CONCLUSIONS: The presence of bulking fibre in gut lumen, by unknown mechanisms, reduces the frequency of an inoculated translocating strain of E. coli in caecal contents and on caecal epithelium and prevents its translocation to mesenteric lymph nodes.

Evaluation of the lactulose/mannitol and 51Cr-ethylenediaminetetraacetic acid/14C-mannitol methods for intestinal permeability.

BACKGROUND: We earlier compared the lactulose/mannitol and 51Cr-ethylenediaminetetraacetic acid (EDTA)/14C-mannitol methods for intestinal permeability We have now investigated an increased number of control subjects, with special regard to the influence of urinary volume, sex, age, and smoking on marker excretion, and patients with intestinal disorders, with special regard to correlations between markers. METHODS: The 0- to 6-h urinary excretion of orally administered markers was measured in 65 control subjects and in 70 patients. RESULTS: In the control group excretion of mannitol and 14C-mannitol (small-pore permeability markers) was strongly correlated to urinary volume, whereas such correlation was weak for lactulose and absent for 51Cr-EDTA (large-pore permeability markers). No sex difference in marker excretion was found, but correlation to urinary volume was more pronounced in males. There was a slightly decreasing excretion of markers with increasing age, reaching significance for 51Cr-EDTA and 14C-mannitol; their excretion ratio was unaffected. Smoking did not significantly affect marker excretion. In the patient group the excretion of large-pore markers tended to be higher and that of small-pore markers to be lower than in the control group; correlation between the large-pore markers, between the small-pore markers, and between the large-pore/small-pore marker ratios was higher than in the control group. CONCLUSIONS: Correction for urinary volume substantially reduces variability in small-pore marker excretion. Excretion of both types of markers tends to decrease with age, the large-pore/small-pore marker ratio remaining unchanged. Smoking does not affect small-intestinal permeability. 14C-mannitol is preferred to chemically determined mannitol owing to lower test variability.

Selective translocation of coliform bacteria adhering to caecal epithelium of rats during catabolic stress.

Adult conventional rats were starved for 48 h with or without haemorrhage at 24 h, and translocation of caecal coliforms to mesenteric lymph nodes (MLNs) was measured. Translocation was detected in three of 11 rats without haemorrhage, in 6 of 11 starved and sham-operated rats and in 12 of 22 rats after haemorrhage. In contrast, only one of 13 non-instrumented and fed control rats showed translocation. Translocation was associated with more coliforms adhering to caecal epithelium in rats. Coliform isolates from caecum, caecal epithelium and MLNs were characterised and grouped into different biochemical phenotypes (BPTs) by a biochemical fingerprinting method. Of 291 BPTs detected in the caecum of all rats, 108 were also found on caecal epithelium; 36 BPTs were detected in MLNs, of which 17 were not detected either in the caecum or on the caecal epithelium of the corresponding rats. One isolate from each of these 36 BPTs was selected and compared to the others. Four common (C) BPTs (i.e., C1-C4) were identified among them. Strains of C1 formed the majority of isolates from the caecum (79%), caecal epithelium (71%) and MLNs (91%). In contrast, C2-C4 had a significantly lower incidence both in the caecum and on the caecal epithelium, but not in the MLNs. These findings indicate that not all caecal coliforms adhere to the epithelium during catabolic stress and that for translocation to occur, other bacterial properties besides adhesion are needed. It is also concluded that coliforms with a low incidence in the caecum can translocate with the same efficiency as those with a high incidence.

Starvation increases the number of coliform bacteria in the caecum and induces bacterial adherence to caecal epithelium in rats.

OBJECTIVE: To investigate the impact of starvation for 24 and 48 h on the number of coliform bacteria in the caecal contents, on the mucosal adherence of coliform bacteria, and on bacterial translocation in rats. DESIGN: Open prospective study. SETTING: University departments of surgery and microbiology, Sweden. MATERIAL: 46 adult male Sprague-Dawley rats. INTERVENTIONS: 19 rats served as controls, and were fed until samples were taken. Six animals were starved for 24 h and another 15 for 48 h, with free access to water, and then anaesthetised before blood, mesenteric lymph nodes (MLN), caecum, and caecal contents were sampled. To verify bacterial translocation in this strain of rats, another six rats underwent controlled haemorrhage for 60 min to reduce the blood pressure to 55 mm Hg mean arterial pressure (MAP). These rats had free access to food and water before haemorrhage but were allowed only water until samples were taken 24 h after haemorrhage. MAIN OUTCOME MEASURES: Presence and number of coliform bacteria in samples taken from caecal contents, caecal epithelium, MLN, and blood. RESULTS: Starvation for 24 h increased the number of coliform bacteria (colony forming units (CFU)/g) in the caecal contents 25-fold (p < 0.05). Starvation for 48 h further increased the number by a factor of 100. The number of coliform bacteria that adhered to the caecal epithelium increased 3,000 times in rats that had been starved for 48 h (p < 0.001). There was no significant difference in translocation (as indicated by cultures from MLN) between rats that had been fed and those that had been starved for 48 h. In 4 of the 6 rats that were bled and then starved for 24 h there were signs of bacterial translocation, which was significantly more than the 1/19 in fed rats (p < 0.05). CONCLUSION: Starvation increases the number of bacteria in the caecal contents and increases bacterial adherence to the caecal epithelium. These changes may contribute to the previously reported increase in bacterial translocation in starved compared wit fed rats that were subjected to stress. The same changes in the gut were observed in animals subjected to haemorrhagic stress in addition to starvation, and in which bacterial translocation was evident.

Perineal excision of the rectum.

An intersphincteric and perimuscular approach was employed for perineal excision of the rectum in 33 patients who had previously undergone total colectomy with preservation of the rectum. Laparotomy was avoided in 28 of the 29 patients who had had closure of the rectal stump with ileostomy. Of the four patients (two with ileorectal anastomoses and two with sigmoid mucous fistulas) for whom laparotomy was planned, this was considered to be much less extensive than would otherwise have been required. It is concluded that in patients who have previously undergone total colectomy for inflammatory bowel disease, subsequent perineal excision of the rectal stump without laparotomy is frequently possible.

Hyperosmotic glucose infusion during hemorrhage does not reduce bacterial translocation in 24 hour-starved rats.

Food deprivation 24 h before stress increases bacterial translocation in hemorrhage. Presently it tested whether hyperosmolality, induced by exogenous glucose infusion to improve plasma refill, prevents or reduces bacterial translocation after experimental hemorrhage in 24 h food-deprived rats. Rats were given an i.v. infusion of either 2 mL of 30% glucose (G) or the same volume of .9% NaCl (C) while simultaneously being submitted to a standardized 60 min hemorrhage period, of moderate or more severe hemorrhage. Blood was not reinfused. Despite development of marked hyperglycemia (p < .001, G vs. C) resulting in significantly greater reductions in packed cell volume (p < .001, G vs. C), bacterial translocation was detected similarly in both groups regardless of whether moderate (10/12-G, 9/12-C) or severe (15/19-G, 15/18-C) hemorrhage was inflicted. It was concluded that hyperglycemic hyperosmolality did not prevent bacterial translocation in these models of hemorrhagic stress in 24 h-starved rats.

Food deprivation increases bacterial translocation after non-lethal haemorrhage in rats.

OBJECTIVE: To investigate whether brief fasting before the induction of hypotension by non-lethal haemorrhage may induce translocation of enteric bacteria to mesenteric lymph nodes or blood in rats. DESIGN: Laboratory experiment. SETTING: University departments of surgery and microbiology, Sweden. MATERIAL: 39 Male Sprague-Dawley rats. INTERVENTIONS: 20 animals were fasted for 24 hours, all 39 then underwent controlled haemorrhage for 60 minutes that reduced the blood pressure to 55 mm Hg. MAIN OUTCOME MEASURES: Differences in blood loss, blood glucose concentrations, and packed cell volume; and aerobic cultures of mesenteric lymph nodes and blood. RESULTS: Fasted rats (n = 20) lost 2.3% of blood volume compared with 2.8% in fed rats (p < 0.001). Packed cell volume dropped by 11.3% in fasted rats and 16.5% in fed rats (p < 0.001). Glucose concentrations rose by 7.0 mmol/l in fasted rats compared with 21.0 mmol/l in fed rats (p < 0.001). Mesenteric lymph nodes contained enteric bacteria in 14/20 fasted rats compared with 6/19 fed rats (p < 0.05). In 4 fasted rats blood cultures grew pathogenic bacteria compared with no fed rats (p = 0.11). The number of bacteria found in mesenteric lymph nodes was significantly greater in fasted than in fed rats (p = 0.01). CONCLUSIONS: Brief fasting before hypotension caused by non-lethal haemorrhage was associated with significantly increased bacterial translocation compared with fed animals. Increases in blood glucose concentrations and plasma refill may have had a protective effect in fed rats. These experiments may be of clinical relevance as elective operations are usually preceded by overnight fasting.

Glutamine supplementation does not prevent bacterial translocation after non-lethal haemorrhage in rats.

OBJECTIVE: To find out whether supplementation of an enteral diet with glutamine would reduce translocation of bacteria to mesenteric lymph nodes or blood after major haemorrhage in rats. DESIGN: Open randomised study. SETTING: University departments of surgery and microbiology, Sweden. MATERIAL: 49 Sprague-Dawley rats. INTERVENTIONS: Rats were fed enterally for 7 days on diets supplemented with either glutamine or an isonitrogenous amount of non-essential amino acids. After feeding, 8 experimental and 8 control rats underwent sham operation; 9 and 7, respectively, underwent moderate haemorrhage (to 65 mm Hg); and 9 and 8, respectively, underwent severe haemorrhage (50 mm Hg) without reinfusion. MAIN OUTCOME MEASURES: Microbiological analyses of samples of blood and mesenteric lymph nodes taken 24 hours after haemorrhage. RESULTS: The median (interquartile) number of colony forming units/mesenteric lymph nodes after moderate haemorrhage in animals who were given glutamine supplementation was 11 (0-34) and in control animals 20 (0-178). After severe haemorrhage the corresponding figures were 199 (10-310) and 22 (0-187). No pathogens were isolated from blood cultures. CONCLUSION: Glutamine supplementation before haemorrhage did not reduce bacterial translocation to mesenteric lymph nodes in this rat model.

Composition and diversity of intestinal coliform flora influence bacterial translocation in rats after hemorrhagic stress.

Coliform bacteria are the most frequently reported bacteria to translocate after hemorrhage. We investigated the correlation between composition and diversity of the cecal coliform flora and the degree of translocation in a rat model of hemorrhagic stress. Two groups of nine rats each were bled to 60 and 50 mm Hg mean arterial blood pressure, respectively. A sham-operated group without bleeding (n = 9) and a noninstrumented group (n = 6) served as controls. From each rat, 40 coliform isolates from the cecum and up to 16 from positive mesenteric lymph node (MLN) cultures were tested with an automated biochemical fingerprinting method. The phenotypic diversity of coliforms in each cecal sample was calculated as Simpson's diversity index (DI), and similarities between bacterial types in different samples were calculated as population similarity coefficients. Three rats in the sham-operated group and seven in each of the bled groups showed bacterial translocation. Of the different biochemical phenotypes (BPTs) found in the cecum of bled rats (mean, 6.5 BPTs), only a few were detected in MLNs (mean, 1.9 BPTs per MLN), with Escherichia coli being the dominant species. The translocating E. coli strains were mainly of two BPTs. Rats showing no translocation either did not carry these strains or had a high diversity of coliforms in the cecum. Furthermore, translocation of these coliform types was independent of their proportion in the cecum. In bled rats, the diversity of coliforms (mean DI, 0.53) was significantly higher than that in control groups (mean DI, 0.30; P = 0.004), suggesting that hemorrhage stimulates an increase in diversity of cecal coliforms. Rats with similar coliform flora and subjected to the same treatment showed similar patterns of translocation. Our results suggest that the composition of the coliform flora is an important factor in translocation and that certain coliform strains have the ability to translocate and survive in MLNs more easily than others.

Glutamine supplementation does not prevent small bowel mucosal atrophy after total parenteral nutrition in the rat.

Glutamine supplementation to non-lipid parenteral nutrition has been demonstrated to attenuate villus atrophy and increase mucosal DNA content in the rat. This study was performed in order to determine the effects of glutamine supplementation to a balanced TPN mixture (including lipids) on epithelial cell kinetics using autoradiography. Male Sprague-Dawley rats were used. Group 1 (control) received food and an intravenous saline infusion. Group 2 received an intravenous TPN mixture including lipids but without glutamine. The same TPN mixture, glutamine replacing an isonitrogenous amount of non-essential amino acids, was given to Group 3. Animals were fed for 7 days, whereafter blood and intestinal samples were taken 1 h after injection of tritiated thymidine. Microscopy of specimens from proximal jejunum revealed a significant reduction in the number of cells in crypts and villi in both TPN groups (2 and 3) compared to orally fed animals (p < 0.001). Epithelial cell numbers were not significantly different in Group 2 and 3. Similarly, the labelling index (number of labelled cells/number of crypt cells) was not affected by glutamine administration. In plasma, glucagon concentrations in Group 2 (TPN without glutamine) seemed to decrease compared to Group 1 and 3 (p = 0.06). In this study, glutamine supplementation did not affect apithelial atrophy or cell proliferation. It is concluded, that the effects of glutamine on mucosal atrophy and renewal in jejunum may depend on the composition of the TPN mixture supplied during parenteral feeding.

[Malnutrition common in Swedish hospitals. Risk of complications and prolonged care increases]. / Undernäring vanligt vid svenska sjukhus. Risken för komplikationer och förlängd vårdtid ökar.

The occurrence of malnutrition has been investigated at four hospitals and the underlaying factors evaluated. The results suggest that malnutrition is still a manifest clinical problem at Swedish hospitals, and that it is associated with an increased risk of complications and prolonged care. During hospitalisation a negative nitrogen and energy balance is observed. It is important to identify patients at risk, as the prevention of undernourishment would appear to be a more effective approach than the treatment of established malnutrition.