Intravenous Hyperalimentation Research Articles

Non-albicans Candida infections in patients with hematologic malignancies

The epidemiology of invasive Candida infections is characterized by a recent decline in Candida albicans and C. tropicalis with a concomitant increase in the incidence of non-albicans Candida species such as C. glabrata and C. krusei, a phenomenon at least partly ascribed to triazole use. Of particular concern is the recognition that these organisms are multiresistant, adding a new dimension to the challenge of management. C. lusitaniae, though uncommon, mainly presents as breakthrough fungemias in patients on antifungal therapy. C. parapsilosis, an organism of relatively low virulence, plays an increasing role because of its ability to cause intravenous line and hyperalimentation fluid colonization. Emergence of azole-resistant (relative or absolute) Candida species is being met by a new class of antifungal agents namely the echinocandins and a new generation of broad-spectrum triazole agents. This article addresses the biology, epidemiology, prognostic factors, and management of an emerging group of pathogens such as non-albicans Candida.

Elemental and intravenous total parenteral nutrition diet-induced gut barrier failure is intestinal site specific and can be prevented by feeding nonfermentable fiber.

Parenteral nutrition and elemental diets both cause bacterial translocation, immune dysfunction, and increased infection in laboratory animals, whereas elemental diets, with or without fiber, ameliorate some, but not all gut barrier failure. The purpose of this study is to investigate, in an Ussing chamber system, whether elemental vs. parenteral diets induce gut barrier failure in specific anatomical sites in the intestine and whether fiber can ameliorate this phenomenon. Controlled study in laboratory animals. University laboratory. Male Sprague-Dawley rats. Nutritional support was provided to rats for 7 days by oral total parenteral nutrition (TPN; elemental diet) 307 kcal/kg/day, intravenous TPN (parenteral diet) 307 kcal/kg/day via jugular venous catheters, or rodent chow (controls). Permeability to bacteria in intestinal segments of ileum, jejunum, and colon was evaluated in an Ussing chamber. Results were correlated with bacterial translocation to the mesenteric lymph nodes. Intravenous TPN caused greater bacterial translocation in all small intestinal segments and the cecum when compared with chow (p <.05). Oral TPN caused gut barrier failure only in the ileal segment, but not in the remainder of the small intestine (p <.001). Addition of cellulose provided a greater protection of the ileum to permeability than did pectin (p <.01). TPN causes global intestinal barrier failure, but elemental diet prevents barrier failure in parts of the small intestine other than the ileum. The addition of cellulose fiber to elemental diet can ameliorate further barrier failure in the ileum.

A case of Esophageal submucosal dissection

A 75 year-old female was admitted to our hospital complaining of hematemesis and chest pain after food ingestion. Urgent upper-endoscopy revealed the existence of esophageal submucosal hematoma with dissection extending the posterior wall of the entire esophagus. The esophagograms showed so-called double barrelled esophagus. The CT scan of the chest revealed thickening of the esophageal wall and air appearance beside the true esophageal lumen. Fasting and intravenous hyperalimentation were prescribed on admission. Her condition and the endoscopic findings improved immediately. The endoscopic examination on the 22 day of hospitalization showed that the elevated lesion had disappeared and the esophagograms also improved. She started to take meal, however, the symptoms did not relapse. Generally speaking, the prognosis of this disease is excellent under the conservative therapy. In this case, it seemed that a sudden rise of the internal pressure of the esophagus injured blood vessels in the submucosa and caused the submucosal hematoma.

Nutritional Management of Neonatal and Infant Liver Disease

After completing this article, readers should be able to: 1. Describe the caloric requirements of a neonate who has chronic liver disease. 2. Identify the vitamin and mineral deficiencies associated with cholestasis and the methods used to correct these deficits. 3. Describe the relationship between total parenteral nutrition and the development of chronic liver disease. 4. Delineate the relationship between malnutrition at the time of liver transplantation and subsequent morbidity and mortality. 5. List the best measurements of nutrition assessment in infants who have chronic liver disease. The liver is involved in many of the body’s metabolic processes, including: regulation of protein, fat, and carbohydrate metabolism; vitamin storage and activation; and detoxification and excretion of waste products. The healthy liver synthesizes and excretes bile salts. With cholestatic liver diseases, poor bile flow results in fat malabsorption because micelles, which solubilize long-chain fatty acids, cannot form without bile salts. Fat malabsorption results in enteric losses of the fat-soluble vitamins A, D, E, and K. Impaired liver function can lead to nutrient deficiencies and eventually protein-energy malnutrition. All of these factors, combined with the common symptoms of anorexia and poor dietary intake, make malnutrition common in chronic liver disease, particularly if it occurs in infants, who are more vulnerable to the debilitating effects of malnutrition because of their higher energy and growth requirements. A wide range of deficits occurs in most chronic liver diseases of children (Table 1⇓ ). Malnutrition itself may induce further derangements of liver function because the liver requires energy for a number of synthetic, storage, and detoxification functions. View this table: Table 1. Nutritional Risk Factors in Acute and Chronic Liver Disease The need for aggressive, early nutrition support in neonates has been well established and discussed extensively. Some centers routinely use a “standardized” approach to nutrition support; we use a “tailored” approach that entails parenteral or …

Analysis of predisposing clinical and laboratory findings for the development of endogenous fungal endophthalmitis. A retrospective 12-year study of 79 eyes of 46 patients.

To analyze the predisposing factors for the development of endogenous fungal endophthalmitis (EFE) for its early diagnosis and treatment. Seventy-nine eyes of 46 patients with EFE treated in the 12-year period between 1986 and 1998 were included. A retrospective analysis was conducted in respect to age, sex, underlying disease, visual acuity, findings in the anterior and posterior segments, fungal culture of surgical specimens, fever of unknown origin, neutrophils < or = 500/mL, Cand-tec > or = x 4, beta-D-glucan > or = 20 pg, and final visual acuity. The patients were 34 men (74%) and 12 women (26%) between 18 and 78 years of age (mean 57.2 years). Thirty-three of the 46 patients (72%) also were diagnosed with cancer. Fungal infiltration limited to the retina (Stage I) was noted in 13%, budding in the vitreous cavity (Stage II) in 40%, vitreous opacity (Stage III) in 29%, and retinal detachment with Stage III (Stage IV) in 18% of 79 eyes with EFE. Forty patients (87%) were undergoing intravenous hyperalimentation (IVH). The mean interval between the start of IVH and the onset of disease was 11 days. Vitreous surgery was performed in 26 eyes (33%). Candida albicans was detected from surgical specimens in 38%. Fever of unknown origin was noted in 76%, neutrophils < or = 500/mL in 67%, Cand-tec > or = x 4 in 57%, and beta-D-glucan > or = 20 pg in 90% of subjects. In patients susceptible to opportunistic infection, beta-D-glucan > or = 20 pg (90%), IVH (87%), fever of unknown origin (76%), male sex (74%), the presence of cancer (72%), neutrophils < or = 500/mL (67%), and Cand-tec > or = x 4 (57%) were considered to be predisposing factors for the development of EFE.

Experimental study on in situ tissue engineering of the stomach by an acellular collagen sponge scaffold graft.

We carried out an experimental study to clarify the feasibility of stomach tissue engineering for reconstruction after partial gastrectomy. A collagen sponge scaffold was implanted to support the regeneration of stomach tissue. A 4 cm square area of the anterior wall of the stomach was surgically resected in three beagle dogs, and then reconstructed using the collagen sponge scaffold. The dogs received intravenous hyperalimentation for 14 days after the operation, and a silicone sheet was used as a patch on the luminal side to protect the scaffold from degradation by digestive juice. The silicone sheet was removed endoscopically 4 weeks after the operation, and the surgical defect was observed endoscopically at various time points. At 4 weeks after surgery, the stomach wall had regenerated, but was not yet covered by stomach mucosal tissue. However, at 16 weeks after surgery, mucosa totally covered the regenerated area. Microscopic findings confirmed regeneration of the stomach wall, mucosa, and thin muscular layer. These results show that tissue engineering of the stomach will be feasible in the near future for reconstruction after partial gastrectomy.

A knotted PEG tube

A 63-year-old man, who had undergone sigmoidectomy 3 years earlier for cancer, presented with abdominal bloating, nausea, and vomiting. A diagnosis of small bowel obstruction due to abdominal carcinomatosis was made by imaging studies, and he underwent PEG for gastrointestinal decompression. Intravenous hyperalimentation was initiated. After a 14F drainage tube was inserted into the gastrostomy and placed in the proximal jejunum with endoscopic assistance, the patient experienced symptomatic relief and resumed an oral intake of liquids.

Commentary on “Low Proliferative Rate of Invasive Node-Negative Breast Cancer Predicts for a Favorable Outcome: A Prospective Evaluation of 669 Patients”

By the 1990 NIH Consensus, recognition of the increased risk of recurrence in the node-negative subset of patients led to recommendations for adjuvant treatment in patients at high risk of relapse as defined by unfavorable prognostic factors.4 A useful prognostic factor was required to be 1) significant with independent predictive value validated by clinical testing; 2) feasible, reproducible, and available with quality control; and 3) readily interpretable. In addition to the established factors of size, receptor status, nuclear grade, and histology, proliferative rate was included with the caveat that while it correlated with prognosis, up to 25% of specimens were not technically evaluable and quality control of this technical procedure was of concern. William McGuire published a table in the Journal of the National Cancer Institute listing established and investigational prognostic factors.5 The table format suggested that optimal future treatment decisions, especially for these nodenegative patients, could be made based less on hand-wringing than on scientific evidence by using a simple checklist – somewhat like the guidelines on the order sheets many of us use to write intravenous hyperalimentation. In this, Dr. McGuire anticipated Dr. Richard Klausner's concept of tumor

Continuous Renal Replacement Therapy in the Initial Management of Neonatal Hyperammonemia Due to Urea Cycle Defects

After completing this article, readers should be able to: 1. Describe the metabolic acidosis that may be seen in urea cycle defects. 2. Delineate the most important factor in determining neurologic outcome in urea cycle defects. 3. Explain the factors that affect the blood ammonia concentration in continuous renal replacement therapy (CRRT). 4. Delineate the most difficult issue in pursuing CRRT in neonates. 5. Describe the morbidities associated with CRRT. MP was born at 39 weeks' estimated gestational age by vaginal delivery to a 35-year-old gravida 3 para 2 woman who had an uncomplicated pregnancy. The 3- and 6-year-old female siblings of the patient were healthy. Apgar scores were 8 at 1 minute and 9 at 5 minutes. The newborn was discharged to home after a 2-day stay in the well baby nursery during which time she appeared to be alert and was breastfeeding appropriately. She presented to the emergency department less than 1 day later after her parents noted increasing lethargy and very poor feeding at home. She was admitted to the neonatal intensive care unit (NICU). Results of a complete blood count with differential count and C-reactive protein evaluation were unremarkable, but the patient progressed to worsening lethargy, respiratory failure, and abdominal distension requiring intubation within hours of admission. The anterior fontanelle was soft on admission physical examination. Further testing revealed a base deficit of 6.1 on arterial blood gas, serum ammonia level of 810 mcmol/L (1,134 mcg/dL), serum lactate level of 5.6 mmol/L (5.6 mEq/L), and serum pyruvate level of 0.06 mmol/L. Results of liver function tests were abnormal, and the infant had a prothrombin time of 35.9 seconds, a partial thromboplastin time of 54.3 seconds, and a fibrinogen concentration of 1.75 g/L (175 mg/dL). Genetic and nephrology consultations were requested immediately. Additional metabolic studies were obtained, including measurement of plasma amino …

Bombesin recovers gut-associated lymphoid tissue and preserves immunity to bacterial pneumonia in mice receiving total parenteral nutrition.

To study the ability of bombesin (BBS) to recover gut-associated lymphoid tissue (GALT) and preserve immunity in a lethal model of Pseudomonas aeruginosa (Ps) pneumonia in mice receiving total parenteral nutrition (TPN). TPN causes depression of mucosal immunity compared with enterally fed animals, which may explain the increased incidence of pneumonia in parenterally fed trauma patients. BBS prevents this TPN-induced GALT atrophy, depressed gastrointestinal and respiratory tract IgA levels, and impaired antiviral IgA-mediated mucosal immunity. The authors examined whether some supplement could be added to TPN to avoid this GALT atrophy and lower the incidence of infectious complications in the parenterally fed animal. Male mice were randomized to chow or intravenous (IV) TPN. After 5 days of IV TPN, mice received 0, 1, 2, or 3 days of BBS IV three times a day and then were killed to harvest Peyer's patch, intraepithelium, and lamina propria for cell yields. Gastrointestinal and respiratory tract IgA levels were analyzed by enzyme-linked immunosorbent assay. Next, mice underwent intranasal inoculation with liposomes alone (nonimmune) or liposome-containing Ps polysaccharide. Ps immune mice were catheterized and randomized to chow, IV TPN, or IV TPN + BBS. The liposome group received chow but no IV catheter. These mice were given an LD90 dose of intratracheal Ps, and death rates were recorded. GALT and gastrointestinal and respiratory tract IgA levels improved to those in chow-fed mice after 3 days of BBS. Immunization reduced the death rate from 92% in chow-fed liposome-only animals to 20% in immunized animals. TPN-fed animals lost their mucosal immunity, with a death rate of 86% compared with 21% in the TPN + BBS group. The results demonstrate that BBS reverses TPN-induced changes in GALT and preserves mucosal immunity. Ps immunization reduces the death rate in a gram-negative pneumonia model and maintains gastrointestinal and respiratory immunity in Ps immune mice receiving IV TPN.

下位脳神経麻痺による咽頭期嚥下障害に対する機能改善手術の成績

Oropharyngeal swallowing disorder results from the disruption of the integrated mechanism of deglutition. This disruption occurs when the lower cranial nerves have been paralyzed due to a cerebrovascular accident or by a skull base lesion. In this article, we postoperatively evaluated the outcomes of 26 patients who had undergone surgical intervention for severe dysphagia caused by lower cranial nerve deficits. The ages of the patients ranged from 22 to 79 years, with an average of 58 years. Etiology of dysphagia consisted of cerebrovascular accidents in 14 cases, skull base lesions in 7, parapharyngeal space lesions in 2, and others in 3. Twenty-one patients had been entirely dependent on tube feeding or intravenous hyperalimentation preoperatively. The series of surgical procedures included cricopharyngeal myotomy (CPM) in 10 cases, CPM with laryngeal suspension (LS) in 6, CPM with vocal fold medialization (VFM) in 3, CPM with both LS and VFM in 6, and VFM in 1. Twenty-three patients (88%) had success in postoperative swallowing function improvement, and oral food intake was restored. Although structured swallowing rehabilitation is mandatory for patients with pharyngeal swallowing disorders, surgical strategies should be considered as a choice of treatment for patients with prolonged pharyngeal swallowing dysfunction.

Route of nutrition influences intercellular adhesion molecule-1 expression and neutrophil accumulation in intestine.

The levels of intestinal interleukin 10 and interleukin 4, inhibitors of intercellular adhesion molecule-1 (ICAM-1) expression, decline with total parenteral nutrition (TPN). These cytokine changes induced by lack of enteral nutrition may increase ICAM-1 expression, resulting in polymorphonuclear neutrophil accumulation in intestine. Prospective randomized experimental trials. Laboratory. Male mice. Sixty-three mice were randomized to chow, intravenous TPN, or intragastric TPN. Experiment 1: After diet manipulation, iodine 125-labeled anti-ICAM-1 antibody and iodine 131-labeled nonbinding antibody were injected to quantify ICAM-1 expression on endothelial cells in the lung, liver, kidney, and small intestine. Measurement of myeloperoxidase was used to quantify polymorphonuclear neutrophil accumulation in the organs. Experiment 2: Intestine was harvested for both ICAM-1 and myeloperoxidase levels after chow refeeding of mice in the intravenous TPN group. In experiment 1, uninjured mice fed intravenous TPN showed significantly increased intestinal ICAM-1 expression and polymorphonuclear neutrophil accumulation with no significant changes in the lung, liver, or kidney. No changes occurred in mice fed chow or intragastric TPN. In experiment 2, reinstitution of enteral feeding returned intestinal ICAM-1 and myeloperoxidase levels to normal. Gut changes associated with lack of enteral feeding induce endothelial changes and an immunologic response, which may influence subsequent responses to injury.

Intrathoracic esophageal replacement in the dog with the use of an artificial esophagus composed of a collagen sponge with a double-layered silicone tube

Objectives: Intrathoracic esophageal replacement with an artificial esophagus is considered difficult. We attempted to replace the intrathoracic esophagus with an artificial esophagus composed of a collagen sponge with a double-layered silicone tube and examined the state of host tissue regeneration. Methods: A 5-cm long gap was created in the intrathoracic esophagus in 9 dogs and repaired by interposition of our prosthesis. The dogs were fed only by intravenous hyperalimentation for 28 days. The silicone tube was removed at 29 days after the operation, and oral feeding was reintroduced. Results: One dog was put to death at each of the following times: 1, 2, 3, 3, 6, 12, and 24 months after the operation. One dog is still surviving without problems after more than 26 months. One dog died of malnutrition at 10 months. In all dogs, the host regenerated tissue had replaced the resulting gap at the time of silicone tube removal. The mucosa had fully regenerated within 3 months and the glands within 12 months. The process of stenosis and shrinkage was complete within 3 months and did not advance thereafter. The lamina muscularis mucosae were observed as islets of smooth muscle within 12 months. Although the skeletal muscle regenerated close to the anastomoses, it did not extend to the middle of the regenerated esophagus even after 24 months. Conclusions: Use of a collagen sponge with a double-layered silicone tube was shown to be feasible even in the thorax and to allow the regenerated host tissue, consisting of the mucosa, glands, and lamina muscularis mucosae, to replace the esophageal gap. (J Thorac Cardiovasc Surg 1999;118:276-86)

Experimental replacement of the thoracic esophagus with a bioabsorbable collagen sponge scaffold supported by a silicone stent in dogs.

We manufactured an esophageal prosthesis made of a collagen sponge supported by an inner silicone tube. The collagen was derived from porcine skin and was crosslinked by dehydrothermal treatment. We implanted our prosthesis in nine dogs after resecting a 5 cm length of the thoracic esophagus. Intravenous hyperalimentation was performed for 4 weeks after the surgery. After 29 days, the inner silicone tube was removed endoscopically and oral feeding was restarted immediately. All nine dogs survived more than 1 month, and three of the nine dogs survived for more than 1 year. Endoscopically, the luminal surface of the regenerated esophagus was covered with a lustrous, smooth mucosa, but stenosis was observed in the midregion of the regenerated esophagus. Microscopically, no foreign material remained at the reconstructed site 1 month after surgery; the collagen sponge was absorbed and replaced by host tissue. Complete epithelization was observed within 3 months. Regeneration of the lamina muscularis mucosae, esophageal glands, and skeletal muscle were observed near the anastomoses. Our artificial esophagus holds promise for esophageal reconstruction in a clinical setting, even in the thorax.

Route and type of nutrition influence mucosal immunity to bacterial pneumonia.

To develop a model of established respiratory immunity against Pseudomonas aeruginosa pneumonia and to investigate the effects of route and type of nutrition on this immunity. Diet influences the ability of gut-associated lymphoid tissue (GALT) to maintain mucosal immunity. Complex enteral diets and chow maintain normal GALT populations against established IgA-mediated antiviral respiratory immunity. Both intravenous and intragastric total parenteral nutrition (TPN) produce GALT atrophy, but only intragastric TPN preserves established antiviral immunity. The authors hypothesized that both GALT-depleting diets (intragastric and intravenous TPN) would impair immunity against bacterial pneumonia. P. aeruginosa was administered intratracheally to determine the mortality rate at increasing doses, and liposomes containing P. aeruginosa antigens were used to generate effective respiratory immunization. In the final experiment, mice received liposomes containing P. aeruginosa antigens to establish immunity and then were randomized to chow, complex enteral diets, intragastric TPN, or intravenous TPN. After 5 days of diet, mice received live intratracheal P. aeruginosa, and the death rate was recorded at 24 and 48 hours. The LD50 and LD100 were 9 x 10(7) and 12 x 10(7), respectively. Immunization reduced the mortality rate from 66% to 12%. This immunization was maintained in mice fed chow or a complex enteral diet and was lost in animals receiving intravenous TPN. Intragastric TPN partially preserved this respiratory immunity. Protection against bacterial pneumonia can be induced by prior antigenic immunization. This protection is lost with intravenous TPN, partially preserved with a chemically defined enteral diet, and completely preserved with chow or complex enteral diets. Both route and type of nutrition influence antibacterial respiratory tract immunity.

Quantitative analysis of factors to influence the environment of the clean room and clean bench during preparation of intravenous hyperalimentation (IVH) admixtures

We quantitatively studied factors influencing the environment cleanliness for intravenous hyperalimentation (IVH) admixing. The environment cleanliness was evaluated by measuring the counts of particles (> 0.5 micron) and bacteria floating in 1 ft3 of the air inside the clean room (23.6 m3) and in the clean bench built in the department of pharmacy, The University of Tokyo Hospital in 1998. The number of particles at the center of the clean room during IVH admixing by 4 pharmacists was higher than that at the medicine passing area (150 +/- 50/ft3 vs. 260 +/- 60/ft3; mean +/- S.D., n = 12). The cleanliness inside the clean room was improved as the measurement point became higher from the floor (600 +/- 180/ft3, 150 +/- 50/ft3, and 35 +/- 15/ft3 at 50, 100, and 150 cm height, respectively) and the number of persons working inside the room decreased. The changes in the counts of floating bacteria were similar to that of floating particles under the same conditions. In addition the effect of disinfection on the counts of bacteria was clearly observed. When the cleanliness of the room became lower by turning off the air conditioning, the particle counts inside the clean bench became lower along with the distance from the front glass becoming deeper (i.e., 1400 +/- 550/ft3, 140 +/- 70/ft3, and 40 +/- 30/ft3 at 0, 5, and 15 cm, respectively). From these lines of evidence, the following items were suggested in order to maintain the environment cleanliness for IVH admixing. First, the number of persons residing in the clean room should be kept to be minimum. Second, the clean bench should be set up in the center of the clean room. Finally IVH admixing operation should be performed at more than 15 cm depth inside the front glass surface of the clean bench. Moreover, the effect of mopping-up of the clean room with 0.1% benzethonium chloride clearly demonstrated the importance of disinfection on a routine basis.

頭頚部腫よう症例での内視鏡的胃ろう造設術

Pericutaneous endoscopic gastrostomy (PEG) was initially introduced in 1980, and has been applied to feed patients with cerebrovascular diseases.Head and neck tumors and operations for such diseases often cause swallowing problems. Gastric tube insertion has been the most common method to resolve such conditions. However, several disadvantages such as necessity of frequent exchange of the tube, and gastroesophageal refiux have been reported. Intravenous hyper-alimentation is also a common strategy to feed patients. However, infections sometimes occur.We report here, our findings using PEG for patients with head and neck tumors pre- or postoperatively. We recommend PEG as a useful method to provide good nutrition to patients with swallowing disturbance.

薬歴の解析 （第４報） 癌性腹膜炎を伴う末期癌患者への既製高カロリー輸液投与による代謝性アルカローシスの発現と特殊処方設計

We noted that terminal stage cancer patients who are continuously administered ready-made hyper-alimentation drip infusions tend to develop metabolic alkalosis while normal serum potassium values. We therefore investigated the medicinal histories of these patients using a computer analysis while also monitoring the drip infusion data to explain this phenomenon.Consequently we observed that the administration of hyper potassium, furosemide and dexamethasone often results in a decrease in the whole body potassium value in spite of the normal value in the serum finding indicated the occurrence of metabolic alkalosis in terminal stage cancer patients with peritoneal carcinomatosa. Based on these findings, we designed the special menu of intravenous hyper-alimentation drip infusions for patients with peritoneal carcinomatosa.

Alteration of the Intestinal Intraepithelial Lymphocytes during Total Parenteral Nutrition

Total parenteral nutrition (TPN) may cause increased rates of bacterial translocation (BT), possibly due to a loss of epithelial integrity. Cultured epithelial cells have been shown to lose tight junction integrity with interferon gamma (INF-γ) an action which may be blocked by transforming growth factor beta (TGF-β). Because intraepithelial lymphocytes (IEL) are a rich source of these cytokines in the epithelium, we hypothesized that changes in the IEL, while mice were receiving TPN, may be responsible for the mediation of such cytokine responses. C57BL/6 mice were randomized to a Control group which received intravenous saline and mouse chow, or a TPN group which received intravenous TPN with no oral feeding. At 7 days mice were assessed for BT. Isolated IEL were stained for CD4, CD8, and CD44 (as a marker for memory T-cells) and flow cytometry was performed. mRNA was extracted from remaining IEL for cytokine expression. Reverse transcriptase polymerase chain reaction was performed to detect TGF-β1 and INF-γ mRNA expression. Densities were standardized to β-actin expression. The incidence of BT to mesenteric lymph nodes was 40 and 12.5%, for the TPN and Control groups, respectively. TPN led to statistically significant decreases in the CD4+, CD8-; CD4+, CD8+; and the CD8+, CD44+ IEL subpopulations (P< 0.05). mRNA expression for INF-γ was increased by 53% (P< 0.05), and TGF-β1 mRNA expression was decreased by 75% (P= 0.1) in the IEL of TPN mice when compared with Controls. TPN led to significant changes in the IEL. Such alterations of the IEL phenotype and function may be a critical mechanism by which epithelial integrity is lost.

Acute mediastinitis due to esophageal perforation —A case report—

A 55-year-old female consulted her family physician because of pharyngeal discomfort after eating a fish. She underwent rigid fiberscopy and was pointed out a fish bone. Family physician failed to extract the bone and the patient was referred to our hospital. However, there was no fish bone in the esophagus when she underwent second rigid fiberscopy. After eight days she complained of dyspnea and was referred to our hospital again. Chest X ray film showed marked enlargement of the mediastinum and she was diagnosed as acute mediastinitis. She underwent mediastinal drainage by thoracotomy. So tiny perforation was found in cervical esophagus by endoscopy that primary suture was not done. After two months' follow up with intravenous hyperalimentation, there was still esophageal perforation. She underwent the second operation of primary closure with reinforcement using sternocleidomastoid muscle. Two weeks after the second operation esophagogram still showed a fistula. So she received injections of alprostadil and factor XIII. One month after the injections esophagogram showed a diverticulum without leakage.