Does gastric volume in trauma patients identify a population at risk for developing pneumonia and poor outcomes?

BACKGROUND: Trauma patients may have full stomachs or impaired airway reflexes that place them at risk for aspiration and pneumonia. Our hypothesis was that trauma patients with larger gastric volumes as measured by abdominal computed tomography (CT) at admission have higher rates of pneumonia and worse outcomes. METHODS: We matched an initial cohort of 81 trauma patients with an admission CT of the abdomen and a diagnosis of pneumonia by Injury Severity Score and Abbreviated Injury Score of the head and chest with a control group of 81 trauma patients without pneumonia. We estimated gastric volumes on CT and compared variables using chi-square, t-tests, receiver operating curve analysis, and regression analysis. RESULTS: Patients with pneumonia had larger gastric volumes than those without pneumonia (879 cm(3)versus 704 cm(3); P = 0.04). Receiver operating curve analysis gave a gastric volume threshold value of 700 cm(3) as a predictor of pneumonia. Patients with a gastric volume ≥ 700 cm(3) had more pneumonia (61% versus 41%; P = 0.01), stayed longer in the hospital (27.6 versus 19.7 d; P < 0.05) and the intensive care unit (18.4 versus 12.5 d; P = 0.01), required more days on the ventilator (18.1 versus 12.0 d; P = 0.02), and had a trend toward increased mortality (17% versus 11%; P = 0.2). On multivariate analysis, nasogastric or orogastric tube (odds ratio 3.0; P = 0.004) and gastric volume >700 cm(3) (odds ratio 2.7; P = 0.004) were independent predictors of pneumonia. CONCLUSIONS: Trauma patients who developed pneumonia had larger initial gastric volumes. A straightforward estimate of gastric volume on admission abdominal CT may predict patients at risk for developing pneumonia and poor outcomes. Clinicians should be especially vigilant in taking precautions against pneumonia and have a lower threshold for suspecting pneumonia in patients with abdominal CT gastric volumes ≥ 700 cm(3).

Is endoscopic mucosal clipping useful for preventing colonic manometry probe displacement?

GOAL: To examine whether endoscopic mucosal clipping prevents probe migration. BACKGROUND: Ambulatory colonic manometry can provide useful pathophysiologic information regarding colonic motor function. However, probe displacement during prolonged recording can be problematic. METHODS: Thirty healthy volunteers underwent 24-hour ambulatory colonic manometry with colonoscopic-assisted probe placement, and fluoroscopic confirmation of the location of most proximal sensor at hepatic flexure. Participants were randomized to 2 groups; in 14 participants (m/f=8/6), the probe was anchored to the colonic mucosa using mucosal clips and in 16 participants, (m/f=9/7), the probe was left unattached in the colon. Magnitude of transducer displacement was assessed by fluoroscopic localization. The difference between the number of transducers in each segment at the beginning (x) and at the end (y) of each study was summed up and divided by 2, to calculate the "displacement score" and this was taken as the main outcome measure. RESULTS: In participants without clipping, the mean (s.d.) displacement score was 1.6 (0.9), implying displacement of transducers by 1.6 colonic segments relative to their initial location. In contrast, there was no displacement of transducers in those who received clipping. Clipping caused no adverse events. CONCLUSIONS: Endoscopic mucosal clipping is safe and effective for prevention of probe displacement, and ensures more accurate temporospatial resolution of data for prolonged colonic manometry recording.

Occult thyroid eye disease in patients presenting with dry eye symptoms.

PURPOSE: To describe the clinical presentation, laboratory features, and treatment outcomes in a series of patients with occult thyroid eye disease (TED). DESIGN: Retrospective observational case series. METHODS: Among 539 patients who were referred for dry eye evaluation over 2 years, 21 were diagnosed with occult TED, based on typical findings in orbital echography. Medical records of these patients were reviewed to collect information on demographics, clinical findings, laboratory studies, and treatment response. RESULTS: All patients presented with symptoms of dry eye. Median age of patients was 57 years (range, 24 to 78 years), with the majority female (86%). No patients carried prior diagnosis of TED or had typical findings of TED such as proptosis, dysmotility, or diplopia. Suspicion of TED was based on conjunctival hyperemia with or without chemosis localized to extraocular muscles (100%), and subtle widening of interpalpebral fissure (48%). Clinical findings included corneal fluorescein staining (57%), rapid tear break-up time (31%), and abnormal Schirmer test (19%). Nineteen percent of patients had other rheumatologic disorders commonly associated with dry eye: Sjögren syndrome (n = 3), and rheumatoid arthritis (n = 1). Patients were treated topically using cyclosporine 0.05% 2 to 4 times a day, with or without steroid. Other treatments were also employed as necessary including warm compresses, artificial tears, and puntal plugs. Majority of patients (76%) had improvement of their symptoms. CONCLUSION: Occult TED is a potential cause of inflammatory ocular surface disease with dry eye symptomatology and should be considered in the differential diagnosis when evaluating dry eye patients.

Ambulatory 24-hour colonic manometry in slow-transit constipation.

BACKGROUND: The colonic neuromuscular dysfunction in patients with constipation and the role of colonic manometry is incompletely understood. AIM: To study prolonged colonic motility and assess its clinical significance. METHODS: Twenty-four-hour ambulatory colonic manometry was performed in 21 patients with slow-transit constipation and 20 healthy controls by placing a 6-sensor solid-state probe up to the hepatic flexure. Quantitative and qualitative manometric analysis was performed in 8-h epochs. Patients were followed up for 1 yr. RESULTS: Constipated patients showed fewer pressure waves and lower area under the curve (p < 0.05) than controls during daytime, but not at night. Colonic motility induced by waking or meal was decreased (p < 0.05) in patients. High-amplitude propagating contractions (HAPCs) occurred in 43% of patients compared to 100% of controls and with lower incidence (1.7 vs 10.1, p < 0.001) and propagation velocity (p < 0.04). Manometric features suggestive of colonic neuropathy were seen in 10, myopathy in 5, and normal profiles in 4 patients. Seven patients with colonic neuropathy underwent colectomy with improvement. The rest were managed conservatively with 50% improvement at 1 yr. CONCLUSIONS: Patients with slow-transit constipation exhibited either normal or decreased pressure activity with manometric features suggestive of colonic neuropathy or myopathy as evidenced by absent HAPC or attenuated colonic responses to meals and waking. In refractory patients, colonic manometry may be useful in characterizing the underlying pathophysiology and in guiding therapy.