Endoscopic feeding tube placement in patients with cancer: a prospective clinical audit of 2055 procedures in 1866 patients.

BACKGROUND: Feeding tube placement in patients with aero-digestive cancer is challenging because of the distortion and/or obstruction of the upper digestive passage. As a result, many patients may receive intravenous fluids and parenteral nutrition instead of enteral feeds. AIM: To audit all the endoscopic feeding tube placements in large sample of patients to determine difficulties, success, reasons for failures and procedure-related complications. METHODS: Audit of all consecutive feeding tube placements from January 1996 to December 2003 was conducted. Tubes were placed depending on the site of cancer and anticipated duration of feeding: naso-gastric tubes, naso-enteral tubes and percutaneous endoscopic gastrostomy. Nutrition support team evaluated these patients. Technical modifications, difficulties, success and complications encountered during the procedure were recorded. RESULTS: Two thousand and fifty-five attempts were made for feeding tube placements (naso-gastric tube - 1637, naso-enteral tube - 177 and percutaneous endoscopic gastrostomy - 241) in 1866 patients. Technical success was achieved in 1969 (96%, 95% CI: 95-97%). Immediate complications occurred in 62 (3%, 95% CI: 2-4%), seven needed hospitalization and one patient died of tumour perforation caused by naso-gastric tube placement. The technical success and complications rates of the procedures performed by fellows in training were comparable to those performed by attending consultants. CONCLUSIONS: Enteral feeding tubes can be placed in almost all patients with cancer using endoscopic techniques. Adequate training of the endoscopy fellows and sufficient care by nutrition support team help achieve high success with few complications.

Stool test for colorectal cancer screening--it's time to move!

Fecal occult blood testing (FOBT) is the most widely prescribed screening test for colorectal cancer (CRC) because it is simple, non-invasive, and it has been demonstrated that it reduces the mortality due to colorectal carcinomas (CRC). However, guaiac based fecal blood tests (gFOBT) suffer from poor sensitivity, particularly with respect to detecting early stages, as well as low acceptance among the population. Preliminary data on the detection of fecal proteins like calprotectin and tumour-M2-PK indicated that they might have better performance characteristics than the gFOBTs. However, these tests also suffer from low sensitivity and poor specificity especially for detecting early lesions. Recently developed immunological tests (iFOBT) demonstrate a significantly higher sensitivity and specificity. iFOBTs use antibodies specific to human hemoglobulin and therefore are not affected by the necessity of dietary and drug restrictions that otherwise limit the use of gFOBTs. At present iFOBTs seem to be the most cost-effective approach for non-invasive CRC screening. The analysis of fecal DNA represents an emerging new field for early detection of colorectal neoplasia. Small trials of multitarget assays demonstrated a sensitivity for CRC of 62 to 91% and a sensitivity for adenomas of 26 to 73%. The specificity of these assays is high ranging from 93 to 100%. The major drawback of fecal DNA testing, compared with other fecal colorectal cancer screening tests, is the unacceptable high cost.

Prospective evaluation of faecal neutrophil-derived proteins in identifying intestinal inflammation: combination of parameters does not improve diagnostic accuracy of calprotectin.

BACKGROUND: Differentiating symptoms of irritable bowel syndrome from those of organic intestinal disease is a common clinical problem. Several neutrophil-derived proteins have been proposed as a marker of inflammatory bowel disease. AIM: To compare the diagnostic value of faecal calprotectin, lactoferrin and polymorphonuclear neutrophil-elastase in distinguishing inflammatory bowel disease from irritable bowel syndrome. METHODS: Eighty-eight adult patients with a history of chronic diarrhoea of unknown origin were screened. All patients underwent a complete work-up to identify the underlying cause. In addition, a single stool sample was assayed for faecal calprotectin, lactoferrin and polymorphonuclear neutrophil-elastase by enzyme-linked immunosorbent assay. RESULTS: Within the study cohort inflammatory bowel disease was diagnosed in 45 patients and irritable bowel syndrome in 31 patients. The sensitivity and specificity of calprotectin for inflammatory bowel disease were 93% and 100%, respectively. In contrast, the respective diagnostic values for lactoferrin and polymorphonuclear neutrophil-elastase were 82% and 100% and 84% and 87%, respectively. Neither combination of markers did improve the diagnostic power compared with calprotectin alone. CONCLUSIONS: Although all faecal biomarkers studied provide a reliable and simple non-invasive means in the differentiation of inflammatory bowel disease and irritable bowel syndrome, calprotectin appears to represent the most accurate marker to discriminate between these two common causes of chronic diarrhoea.

Sustainable ecosystem management using optimal control theory: part 2 (stochastic systems).

Sustainable development of ecosystems through external ecosystem management is assuming importance for the environmentalists. To that effect, previous work by the authors looked at the option of manipulating population dynamics of the species in an ecosystem to achieve sustainability. Fisher information is used as the quantifying measure of sustainability and optimal control theory is used to derive the control profiles. However, that work considered only deterministic systems. Uncertainty being prevalent in all systems, particularly in natural systems, this paper extends that work to analyse uncertain systems. Predator-prey models are used to model the species populations and different control philosophies are compared. Ito mean reverting process is used to model the stochastic process, and stochastic maximum principle is used to derive the control profiles. The results for the objective of FI variance minimization qualitatively agree with those for the deterministic system, while the results for the FI maximization objective differ. It is observed that the instability associated with the FI maximization objective for deterministic systems is absorbed by the noise introduced by the uncertainty. Quantitatively, it is observed that the degree of uncertainty, along with its presence, is also important to identify the most appropriate management strategy.

Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study.

BACKGROUND: Faecal occult blood testing is an established method of colorectal neoplasia screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Newer immunochemical-based tests, accurate but tedious, require a well-established laboratory set up. There is need for simpler immunochemical tests that can be performed at the out-patient clinic. AIM: To compare the performance characteristics of a new bedside immunological test strip device with a sensitive Guaiac-based and established immunochemical test for detection of faecal occult blood in patients undergoing colonoscopy. METHODS: A total of 389 consecutive patients from four centres who were referred for colonoscopy also provided the stool samples for detection of occult blood without dietary restrictions. Stool tests performed were (i) Guaiac-based, (ii) immunochemical enzyme-linked immunosorbent assay and (iii) bedside immunochemical strip test. RESULTS: At the optimal threshold level, the sensitivity and specificity of the beside immunochemical strip test for detection of significant colorectal neoplasia (adenomas >1.0 cm and carcinomas) were 60% and 95%, respectively. CONCLUSIONS: This bedside immunochemical strip test proved to be a simple, convenient, non-cumbersome and accurate tool with similar performance characteristics for detection of any bleeding lesion including colorectal neoplasia when compared with an established immunochemical faecal occult blood test.

Sustainable ecosystem management using optimal control theory: part 1 (deterministic systems).

The concept of sustainability, an abstract one by its nature, has been given a mathematical representation through the use of Fisher information as a measure. It is used to propose the sustainability hypotheses for dynamical systems, which has paved the way to achieve sustainable development through externally enforced control schemes. For natural systems, this refers to the task of ecosystem management, which is complicated due the lack of clear objectives. This work attempts to incorporate the idea of sustainability in ecosystem management. The natural regulation of ecosystems suggests two possible control options, top-down control and bottom-up control. A comparison of these two control philosophies is made on generic food chain models using the objectives derived from the sustainability hypotheses. Optimal control theory is used to derive the control profiles to handle the complex nature of the models and the objectives. The results indicate a strong relationship between the hypotheses and the dynamic behavior of the models, supporting the use of Fisher information as a measure. As regards to ecosystem management, it has been observed that top-down control is more aggressive but can result in instability, while bottom-up control is guaranteed to give a stable and improved dynamic response. The results also indicate that bottom-up control is a better option to affect shifts in the dynamic regimes of a system, which may be required to recover the system from a natural disaster like the hurricane Katrina.

Total parenteral nutrition.

Parenteral nutrition is a form of therapy in which elemental nutrients (sugars, lipids, amino acids, vitamins and minerals) are given as an intravenous infusion. It is complementary and not competitive to enteral nutrition. While a vast majority of patients can be managed by enteral nutrition, a few patients need parenteral nutrition for survival. Very few patients may need both enteral and parenteral nutrition for short periods. The indications, delivery methods and formulations of parenteral nutrition have been refined in the past 30 years. It is now possible to give parenteral nutrition for prolonged periods at home. Three-in-one parenteral nutrition mixture bags are presently available in India. This article discusses the practical aspects of using parenteral nutrition in everyday practice.

Hydrobiological study of Dahikhuta reservoir.

Physico-chemical parameters and the algae of Dahikhuta reservoir, near Malegaon, Dist. Nasik (Maharashtra) have been investigated during July to December 1998. The results have revealed that reservoir water is classified as oligotrophic on the basis of water quality criteria. This paper also reports algal diversity. Total 19 algal taxa are reported from three classes.

Physico-chemical characteristics and algae of a percolation tank of Pimpalgaon.

Physico-Chemical characteristics and algae of a percolation tank of Pimpalgaon (Dabhadi) have been studied from January to December 1997. The studies reveal that in all 92 algal taxa belonging to four classes i.e. Cyanophyceae, Chlorophyceae, Bacillariophyceae and Euglenophyceae were recorded. Cyanophyceae members show luxurient growth in summer. Euglenoids show better growth during winter and when pH 9.09.

Enteral nutrition by tube feeding in adults.

Patients who cannot eat enough require alternatives to oral feeding. Tube feeding is one such method for patients with a functioning gut. The techniques for the placement of feeding tubes and diets for tube feeding have improved during the past 20 years. Comfortable thin-bore polyurethane tubes are replacing the thicker vinyl tubes. Long term access routes such as gastrostomy and jejunostomy are being done by endoscopic or radiological techniques. Pre-defined formula feeds have reduced the effort and labour involved in the preparation, storage and administration of blenderized tube feeds. However, the use of soft feeding tubes and commercial formulae will increase the cost of nutrition therapy in India. The ultimate cost-effectiveness of tube feeding will depend on whether it is used appropriately during an illness with adequate delivery of feeds, and whether attention is given to small details by a dedicated nutritional support team. A strong commitment to the scientific use of nutritional support is necessary for getting the best results from tube feeding in everyday practice.