Cardioesophageal reflexes: an invasive human study.

Neural reflex arcs from the esophagus and heart have been shown in both animals and man. The purpose of this study was to further investigate these pathways in individuals undergoing cardiac catheterization. A total of 298 patients undergoing cardiac catheterization were asked to participate in the protocol. Thirty patients were able to complete the study. Esophageal manometry and pH were monitored throughout the cardiac procedure. Afterwards, esophageal provocation with ice water, hydrochloric acid, and balloon inflation was performed with observation of cardiac rate and rhythm. Twelve patients with normal coronary arteries developed diffuse esophageal spasm on either esophageal or cardiac provocation. In one patient with abnormal coronary arteries, coronary angioplasty precipitated diffuse esophageal spasm. Esophageal acid sensitivity was increased in patients with normal coronaries as compared to those that were abnormal. The esophageal pain threshold was significantly lower in patients undergoing angioplasty versus those undergoing coronary angiography alone. There was no significant change in esophageal pH during invasive cardiac maneuvers and manipulations. In conclusion, cardiac manipulation can induce esophageal motility abnormalities, but not gastroesophageal reflux. Coronary angioplasty is associated with esophageal hyperalgesia.

Do parotid duct abnormalities occur in patients with chronic alcoholic pancreatitis?

OBJECTIVE: Several studies have suggested that ethanol affects the pancreas and parotid gland. We performed a prospective study to determine whether ductal lesions of ethanol-induced chronic pancreatitis occur in the parotid. METHODS: Parotid sialograms were performed in 11 alcoholic patients who had endoscopic retrograde pancreatograms. Sialograms and pancreatograms were examined in all subjects for ductal abnormalities. RESULTS: Seven of nine patients (77.8%) with ductal lesions of the pancreas had coexistent ductal abnormalities of the parotid gland (Kendall's tau = 0.578, p = 0.035). CONCLUSIONS: Chronic ethanol intake induces ductal alterations in the parotid gland similar to those seen in the pancreas. These results suggest a common histopathological effect of alcohol in the ductal system of the parotid gland and pancreas and raise the possibility that the parotid sialogram could be useful as an adjunct in the diagnosis of ethanol-induced chronic pancreatitis.

Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis.

BACKGROUND: This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis. METHODS: Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission. RESULTS: Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN ($3294 vs $761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth. CONCLUSIONS: TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.

Standardization of clinical criteria required for use of the 12.5 millimeter barium tablet in evaluating esophageal lumenal patency.

BACKGROUND: Although the barium tablet is commonly used in evaluating lumenal patency of the esophagus, the conditions under which the tablet should traverse a normal esophagus have not been established. This study was designed to standardize the minimal criteria required to ensure successful esophageal transit of a commercially available barium tablet in normal subjects. METHODS: Each of 20 volunteers swallowed a standard 12.5 mm barium tablet under fluoroscopy in the supine, 45 degrees incline, and upright positions. Tablets were swallowed dry and with fixed volumes of water (15, 30, 60, and 100 cc). Success of pill passage into the stomach was determined by fluoroscopy at 20, 40, 60, and 90 seconds. RESULTS: Successful pill passage correlated significantly with position (passing 17.0%, 66.5%, and 69.7% in the supine, incline, and upright position, respectively; p < .0001) and volume of water ingested (passing 9.1% when swallowing dry, and 38.7%, 55.8%, 70.0%, and 81.6% with 15, 30, 60, and 100 cc of water, respectively; p < or = .004). Duration of time beyond 20 seconds failed to affect rate of pill passage. Ingestion of 60 cc of water in the incline position was associated with a 95% pill passage, a rate significantly greater than any position at lower volumes. Increasing water volume above 60 cc or assuming the upright position did not increase this passage rate further. CONCLUSIONS: The minimum criteria required to optimize successful transit of a 12.5 mm barium tablet through a normal esophagus is to perform the test in the 45 degrees incline position with 60 cc of water for a period of 20 seconds. Failure of the pill to pass under these conditions may suggest a true structural abnormality of the esophagus.

Clinical application of the metabolic cart to the delivery of total parenteral nutrition.

In critically ill patients, the inaccuracy of predictive formulas for nutritional assessment often leads to inappropriate and potentially detrimental feeding regimens. This study evaluates the clinical utility of the metabolic cart in an urban university hospital setting. Twenty-six studies were performed on each of 26 patients (18 surgical, 8 medical) using an MMC Horizon metabolic cart. Although 58% of patients were overweight, 42% were still shown to have a kwashiorkorlike pattern of malnutrition. Three patients demonstrated a marasmic-like pattern. Fifteen percent of studies showed patients to be hypometabolic and 62% hypermetabolic. Harris-Benedict resting energy expenditure, based on actual or ideal body weight, underestimated needs; however, addition of a metabolic activity factor overestimated needs. Only 32% of patients were fed appropriately; 41% were underfed, and 27% were overfed. Urine area nitrogen correlated poorly with energy expenditure. Measured RQ appropriately reflected substrate utilization in 77% of studies; multiple factors may have caused differences between measured and predicted RQ in 23%. Use of the metabolic cart determines precisely the metabolic state, identifies problems with substrate utilization, and enables the physician to design the most efficacious nutritional regimen.

Early hepatic histologic alterations among chemical (vinyl monomer) workers.

Focal hepatocellular hyperplasia and focal mixed (hepatocytes and sinusoidal cells) hyperplasia are early histological alterations indicative of vinyl monomer exposure. To evaluate their uses in screening chemical workers, 93 liver biopsy specimens from 78 persons were examined in double-blind duplicative fashion. Forty-eight specimens were from exposed chemical workers, 35 of them having liver biopsy(ies) for hepatic test abnormalities and 13 for nonliver -related reasons. A comparison group consisted of 30 nonchemical workers who had undergone liver biopsy for nonliver related reasons. Twenty-three of the exposed workers (48%) had hepatic lesions consistent with exposure: 17 (35%) of these had focal hepatocytic hyperplasia, while 6 (13%) had focal mixed hyperplasia or more advanced lesions. Only five of the comparison group had like findings: four (13%) had focal hepatocytic hyperplasia; one had focal mixed hyperplasia and sinusoidal dilatation. This individual had persistent hepatic test abnormalities with the focal mixed hyperplasia and a sinusoidal dilatation, and on subsequent biopsy, angiosarcoma (and a history of using hair spray containing vinyl chloride propellant ). Ten individuals had 25 multiple biopsies also read double-blindly; 10 had two or more readings of the same biopsy. Duplicate 21 of 23 (91%) and multiple 27 of 28 (96%) biopsy interpretations in the same individual were identical. Only 6% of either duplicate and/or multiple readings disagreed. Both focal hepatocellular and mixed hyperplasia were always associated with abnormalities in hepatic test results of which indocyanine green clearance was the most sensitive and gamma-glutamyl transpeptidase the least specific.(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of trace levels of hexachlorocyclopentadiene and octachlorocyclopentene in body fluids.

A simple, rapid and sensitive method for the analysis of hexachlorocyclopentadiene (C5-Cl6) and octachlorocyclopentene (C5-Cl8) in blood and urine is described. The procedure requires 5.0 mL of blood or urine, and involves the isolation of the compounds from the sample by liquid-liquid extraction, followed by screening and quantification via glass-capillary column gas chromatography with electron-capture detection and confirmation by gas chromatography-mass spectrometry. The assays are suitable for the detection and identification of nanogram quantities of these compounds in body fluids with a lower detection limit of 50 ng/mL for blood and 10 ng/mL for urine.

Stage I adenocarcinoma of the endometrium. A clinical and histopathological study of 65 cases treated with preoperative radium.

To determine if preoperative irradiation should be abandoned in favor of post-hysterectomy irradiation, 65 cases of stage I endometrial carcinomas were analyzed. When no residual tumor or no myometrial invasion was found in the irradiated uterus (38 cases), a 5-year cure rate of 97.3% was obtained. When residual tumor or myometrial invasion was found, there was a 5-year cure rate of 100% in grades 1 and 2 (7 cases) but only a 20% cure rate in grade 3 lesions (5 cases). On the basis of these data there appears to be no reason to abandon preoperative irradiation in stage 1 cases. More extensive irradiation and surgery should be considered, however, in grade 3 lesions invading the myometrium.

Liver disease among polyvinyl chloride production workers.

A protocol for systematic testing of all employees of a chemical plant is presented. This factory manufactures polyvinyl chloride compounds and resins, ABS compounds and resins, and synthetic rubber. The results were reviewed, which led to the discovery of 2 additional cases of angiosarcoma and 11 cases of portal fibrosis. Two of the 11 cases were found to have developed in employees other than polyvinyl chloride production workers.