Long-chain versus medium-chain lipids in acute pancreatitis complicated by acute respiratory distress syndrome: effects on pulmonary hemodynamics and gas exchange.

BACKGROUND AND AIMS: In order to assess the effects of fat emulsions in patients with acute pancreatitis and acute respiratory distress syndrome (ARDS) before the pancreatic injury was complicated by infection, pulmonary hemodynamics and gas exchange were investigated during the administration of long-(LCTs) or medium-chain triacylglycerols (MCTs). METHODS: This prospective trial included nine patients with acute pancreatitis and ARDS; each patient was used as his/her own control. In all cases, the needle aspiration culture of the pancreas was negative. Fat emulsion provided 50% of the energy expenditure. The patients were infused, in random order, with pure LCTs and a 1:1 mixture of LCTs/MCTs on days 1 and 2, over an 8 h period. RESULTS: LCT infusion increased the mean pulmonary artery pressure (MPAP) from 28+/-5 to 35+/-3 mmHg, pulmonary venous admixture (Qva/Qt) from 26+/-5% to 36+/-5% and decreased arterial PO2(PaO2)/fractional inspired oxygen (FIO2) from 210+/-20 to 170+/-20 (P<0.05). The infusion of LCT/MCT 1:1 emulsions increased oxygen consumption (VO2) from 340+/-10 to 398+/-15 ml/min, cardiac output (CO) from 8.8+/-0.2 to 9.5+/-0.5 L/min and CO2 production (VCO2) from 247+/-12 to 282+/-14 mL/min (P<0.05). CONCLUSION: LCT/MCT 1:1 mixtures are recommended in cases of acute pancreatitis and ARDS, even though infusion over a short period increases the metabolic demand.

Splenic abscess. An old disease with new interest.

BACKGROUND/AIMS: To study the demographics, signs and symptoms, causes, risk factors, imaging findings, bacteriologic profile, treatment and outcome of patients with splenic abscess. METHOD: The medical records of 17 patients with splenic abscess at two tertiary-care hospitals between 1989 and 1997 were retrospectively reviewed. The demographic data, physical and radiological findings, treatment, bacteriology reports and outcome of treatment were reviewed. RESULTS: The mean age of patients was 43 years (range 7-79 years). Fever and abdominal pain were the most prominent signs. Seven patients were immunocompromised, three had abscessed hydatic cysts, two were drug users and three suffered from splenic trauma, infarction, and endocarditis, respectively. No predisposing factor was identified in 2 patients. In all cases, CT demonstrated the splenic lesion(s). Staphylococcus species and Bacteriodes were the most common microbes, identified in the blood and abscess cultures. Thirteen patients underwent splenectomy, two medical therapy and two no therapy with respective survival rates of 92, 100 and 0%. CONCLUSION: Splenic abscess is a rare surgical entity encountered mostly in immunocompromised patients. CT scan is the gold standard for the definite diagnosis. Splenectomy is the treatment of choice, while medical therapy should be reserved for unusual pathogens provided that an effective antimicrobial agent is available.

Severe hypothyroidism in patients dependent on prolonged thyroxine infusion through a jejunostomy.

BACKGROUND AND AIMS: Enteral absorption of thyroxine (T4) is variable; the duodenum and jejunum appear to be the most important sites of absorption. Our objective is to demonstrate that T4 infused via a standard jejunostomy may occasionally be poorly absorbed. METHODS: Two patients underwent esophagolaryngeal resection for carcinoma of the cervical esophagus. The procedure was accompanied by complete removal of the thyroid and parathyroid glands. A neck fistula at the gastropharyngeal anastomosis led to a restriction of oral intake; daily requirements of T4 and nutrients were given via the jejunostomy. T4 plasma levels deteriorated and thyroid-stimulating hormone (TSH) levels increased and in the third postoperative week, T4 (300 microg) was administered via a nasogastric tube. RESULTS: Although given a high dose (300 microg) of T4, both patients developed severe hypothyroidism. Infusion of T4 through the nasogastric tube precipitated the normalization of T4 and TSH plasma levels. Both patients (cases 1 and 2) resumed oral intake during the fifth and sixth postoperative weeks respectively. CONCLUSION: T4 malabsorption may occur in patients dependent on prolonged T4 infusion via a standard jejunostomy.

Serum tumor markers in non-Hodgkin's lymphomas and chronic lymphocytic leukemia.

The levels of soluble interleukin-2 receptors (sIL-2R), beta-2 microglobulin (beta-2M), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured in the serum of 50 previously untreated patients with non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia (CLL) as well as in 25 age and sex-matched normal controls. Compared to normal controls, mean serum levels of sIL-2R and beta-2M were significantly increased in both NHL and CLL (p < 0.001) while the increase in ESR and CRP was less marked (p < 0.01 and p < 0.05, respectively). Comparison of these tumor markers with histologic grading showed statistically significant differences only for CRP between low, intermediate and high-grade lymphomas (p < 0.001 and p < 0.05). More advanced stages exhibited higher mean values of all serum markers than early stages (p < 0.001 for sIL-2R, beta-2M and ESR and p < 0.05 for CRP). An association with the presence of b-symptoms was observed only for sIL-2R (p < 0.05). In addition, sIL-2R as well as beta-2M were able to predict time to progression in patients with diffuse large-cell lymphomas. We conclude that of the four tumor markers tested sIL-2R and beta-2M more frequently showed increased serum levels and were associated with clinical stage and/or presence of b-symptoms. Both sIL-2R and beta-2M were also found to have prognostic significance for survival.

Glucose-based versus fat-based total parenteral nutrition (TPN): effects on hepatic function in septic patients complicated with cholestatic jaundice.

A prospective study of two types of total parenteral nutrition (TPN) was carried out in 34 patients suffering from sepsis and complicated liver dysfunction. Group 1 (18 patients) received non-protein energy as glucose plus fat emulsion in a caloric ratio of 19:1, while group 2 (16 patients) received the same energy intake but with a ratio of 1:1. Group 1 exhibited higher levels of bilirubin and alkaline phosphatase with values of 93.5 +/- 25.5 mumol/l and 160 +/- 30 IU/l respectively compared to Group 2, in which the corresponding values were 81.6 +/- 32.3 mumol/l and 120 +/- 10 IU/l (p < 0.05). On the other hand, group 1 had lower levels of serum albumin and serum transferrin with values 25 +/- 1.3 g/l and 40 +/- 20% of normal, compared to group 2 in whom the corresponding values were 28 +/- 8 g/l and 48 +/- 30% of normal (p < 0.05). There were no differences between the two groups, in the absolute number of T-lymphocytes and in transaminase levels. In sepsis complicated by liver dysfunction a 50:50 glucose: fat regimen caused less disturbance of liver function than one consisting almost entirely of glucose.