Parenteral Alimentation Research Articles

Brain Autopsy Findings in a Patient Who Received Lipid Emulsion Therapy for Suspected Drug Intoxication.

Lipid emulsion therapy (LET) is the intravenous administration of lipid solution for parenteral alimentation, especially in preterm infants and adults with debilitating illnesses. It has also been used in attempts of detoxification in suspected cases of drug overdose. Whether this interferes with circulation and/or perfusion is debatable, and it is suggested that it may interfere with coagulation process. The emulsifying agent has been identified microscopically mainly in the lungs of these patients, with rare reports in adults and even more rare ones in the brain; however, although it is rarely reported in other organs, to our knowledge, no reports of gross autopsy findings in the brain are available in the English literature, nor are there reports of pathologic findings after lipid emulsion therapy administration for drug toxicity. Although it is also debated in the literature whether this material forms as an artifact or represents the actual agent, here we report the gross and microscopic autopsy findings in the brain of a patient who received LET for suspected beta-blocker intoxication. It will be beneficial for pathologists who perform autopsies in the forensic or medical settings to be aware of these findings, along with the uses and potential complications of LET.

Postnatal Growth Restriction in Preterm Infants: A Major Impact of Nutritional Practices and Methods of Assessment

Background: Nutritional management of preterm infants represents a significant challenge for most practitioners caring for sick and/or premature babies. Despite aggressive parenteral and enteral alimentation, a considerable number of preterm infants continue to fall far short of expected growth trajectories that match infants of similar gestation in-utero. Postnatal growth failure may be associated with future neurodevelopmental and cognitive impairments. Objective: The aim of the research is to investigate the incidence of postnatal growth restriction (PNGR) and characteristics of nutritional practices and growth parameters in a cohort of preterm infants born <32 weeks’ gestational age (GA) in a single neonatal intensive care unit (NICU). Methodology: This prospective study included 130 preterm infants born <32 weeks’ GA and admitted to the NICU between February 2018 and January 2020. The infants were divided into two groups: A (GA 23–26+6 weeks [n=50]) and B (27–31+6 weeks [n=80]). The association between PNGR and predicting risk factors was evaluated using logistic regression models. Results: PNGR was found in 62 (47%) infants at 28 days of life and increased to 73% of infants at 36 weeks’ postmenstrual age. Low birth weight and GA were independent factors predicting growth failure. PNGR was significantly correlated with birth weight (p < 0.01), length (p < 0.002), and GA (p < 0.03) at birth; however, HC was not a predictor of PNGR at 28 days. At 36 weeks’ PMA or discharge, PNGR was more pronounced in length, with a mean Z-score of -3.0, followed by weight, with a mean Z-score of -2.1, and an HC Z-score of -1.4. Conclusion : PNGR was significantly high in preterm infants <32 weeks’ gestation. A significant nutritional gap still exists between the recommended and actual caloric and protein supplementation, especially in the first few days after birth. Delayed optimization of caloric intake may be insufficient to promote growth trajectories, especially in preterm infants with significant morbidities.

A case report of delayed lower intestinal bleeding after organophosphate poisoning

BackgroundOrganophosphate poisoning is a serious issue and it results in significant casualties in developing countries. Since agriculture remains an important and necessary sector of human society and organophosphate are commonly used in agriculture, it is difficult to prevent organophosphate poisoning. Gastrointestinal bleeding is not a common but life threatening symptom of organophosphate poisoning. We report a rare case of gastrointestine bleeding due to organophosphate poisoning.Case presentationA 78-year-old woman presented to our hospital approximately 12 h after ingesting a mouthful of organophosphate and benzodiazepines in a suicide attempt. Six weeks after successful medical treatment for respiratory failure, she developed recurring melena. Colonoscopy and esophagogastroduodenoscopy findings were negative for ulcers or bleeding. Enteroscopy revealed severe circumferential ulcers with luminal narrowing 10 cm proximal to the ileocecal valve. The patient underwent a 100-cm ileum resection after failed medical treatment and recovered uneventfully. The resected terminal ileum demonstrated severe inflammation and a sharp transitional zone between the healthy and injured mucosa approximately 50 cm proximal to the ileocecal valve. Pathological examination revealed an injured mucosa with inflammatory cell infiltration and structural damage. This case highlights a rare event of OP poisoning with late-onset lower gastrointestinal bleeding, which prolonged the patient’s recovery course and parenteral alimentation period.ConclusionWe report a rare case of a patient with organophosphate poisoning, with late-onset lower GI tract bleeding, which raised clinical awareness regarding the organophosphate poisoning that induce intestinal symptoms.

Chemosensitive Disease Better Predicts Outcome Than Age Following Autologous Heamatopoietic Stem Cell Transplantation in Elderly Patients with Multiple Myeloma

High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (AHSCT) is considered the standard of care as first-line therapy for eligible multiple myeloma patients(Barlogie et al. 1987; McElwain & Powles 1983). Median age at diagnosis of multiple myeloma is 69 years old (SEER 18 2010-2014). Data from the CIBMTR revealed that the number of transplants done per year and the age of recipients are still rising(D'Souza & Zhu 2016). With an expected myeloma prevalence rising by 57% from 2010 to 2030(Smith et al. 2009), the number of older patients considered for AHSCT will increase significantly. Best treatment options for those older patients must therefore be addressed. The assessment of hematopoietic cell transplant comorbidity index score (HCT-CI) (Sorror et al. 2005; Sorror et al. 2009) can be helpful in the selection of candidates for AHSCT. The goal of this study was to identify factors impacting the safety and efficacy of AHCT in older multiple myeloma patients in order to better select those who will benefit from such an intervention.This single center, retrospective study examines outcomes of AHSCT in elderly patients (≥60 years old) with multiple myeloma compared to younger patients (<60 years old). Between January 1, 2011, and September 1, 2015, 93 patients met the inclusion criteria and were included in the study. Patients signed an informed consent and the ethics committee of our institution approved the study. Toxicity was analyzed according to age and HCT-CI. Progression-free-survival (PFS) and overall survival (OS) were analyzed according to age at the time of transplantation, HCT-CI, Revised International Staging System (R-ISS) and disease status at the time of transplant.From the 93 patients included in the study, 49(53%) were included in the younger patient group with a median age at transplant of 54 years-old (range 34 to 59). Forty-four (44) patients were included in the older patient group with a median age at transplant of 65 years-old (range 60 to70). Two thirds (66%) of patients were male. Based on the R-ISSS score, 46% were stage I, 54% were stage II and none were stage III. HCT-CI score was low, intermediate and high in 40%, 32% and 28% of patients respectively. Median karnofsky index was 90 (range 70 to 100). Acute renal failure was more frequent in the older group (p=0,028) at multiple myeloma diagnostic. Light chain disease was more frequent in the younger patient group with 19% compared to 3% (p=0,09). Mucositis was similar in occurrence in both groups with only 5% of grade ≥3 mucositis. No parenteral alimentation was required in the older patient group while 4 patients required it in the younger patient group(p=0,053). The incidence of febrile neutropenia was universal in all patients (100%) within the cohort. The incidence of septic shock and admission to intensive care unit was only 1%. Delirium was diagnosed in 2 older patients (p=0,131). There was no difference in toxicity profile when comparing both groups. Median engraftment for neutrophils was 14 days and 16 days for platelets. Median hospital stay duration was 21 days. Intravenous antibiotics were used a median time of 8 days. There was no difference in resources used during transplant in both groups. Median CD4 count was comparable in both groups at 3 months and at 1 year after transplant. With a median follow-up of 37 months (range 2 to 70), our cohort had a PFS of 24 months with no difference between younger and older patient groups(p=0,234). The median OS was not reached at the time of evaluation for both groups. Estimated 4 years PFS was 21% and OS was 81%. There was no difference between our younger and older patient cohorts (figure 1 and 2). Being in stable or progressive disease was associated with worse PFS (median of 9 months versus 26 months, p<0,0005)(figure 3). Our 1 year NRM was 0% in both groups.In conclusion, AHSCT is a good treatment option in well-selected patients. Comorbidities must be considered and HCT-CI can help clinicians choose carefully those patients. Our study demonstrates that age should not be the limiting factor when considering ASCT in older patients. Toxicity and survival were comparable in both groups. Best timing when to proceed to ASCT is still in investigation. Considering the significantly worse PFS with chemoresistant disease, other treatment options should be considered before AHSCT without age being a consideration. [Display omitted] DisclosuresDelage:AbbVie: Research Funding; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Research Funding; Pfizer: Research Funding.

Comparing the Efficacy and Safety of Roux-en-Y Gastric Bypass with One-Anastomosis Gastric Bypass with a Biliopancreatic Limb of 200 or 160 cm: 1-Year Results of the Tehran Obesity Treatment Study (TOTS)

One-anastomosis gastric bypass (OAGB) has raised concerns about nutritional complications possibly attributed to the biliopancreatic limb (BPL) length. We aimed to assess the results of a conservative approach of OAGB compared with the original OAGB and Roux-en-Y gastric bypass (RYGB) in a 1-year follow-up study. This retrospective study was conducted based on prospectively maintained data in a cohort of patients who underwent either RYGB with a Roux limb of a 150cm and a BPL of 50cm (n = 145), OAGB with a 200-cm BPL (n = 272), or OAGB with a 160-cm BPL (n = 383), from March 2013 to 2017 at three university hospitals by a single surgical team. Groups were comparable regarding age and sex. Mean preoperative body mass indexes of the RYGB, OAGB-160, and OAGB-200 groups were 44.5 ± 5.8, 45.6 ± 6.3, and 46.7 ± 6.4kg/m2, respectively. One-year follow-up rates were 83.4%, 85.3%, and 82.5% for the RYGB, OAGB-200, and OAGB-160 groups, respectively. One-year percent total weight loss values were 33.8 ± 6.7 after OAGB-160 and 35.3 ± 6.9 after OAGB-200 (P= 0.056), which were significantly greater compared with 30.9 ± 8.9 after RYGB (P< 0.001). All groups were comparable regarding remission of type 2 diabetes mellitus, hypertension, dyslipidemia, and fatty liver. Mean operative time was longer with RYGB than with either OAGB techniques. Groups were comparable for postoperative complications except for the incidence of protein-calorie malnutrition (PCM), occurring in 11 patients (4.7%) after OAGB-200, 7 of whom required revisional surgery, in one patient (0.3%) after OAGB-160 who responded to parenteral alimentation, but in no patients after RYGB. After 1year, OAGB with a 160-cm BPL was as effective as OAGB with a 200-cm BPL and RYGB, but safer than OAGB-200. This approach also avoided the need for revisional surgery following postoperative malnutrition.

Biological significance of aminophenyl-β-carboline derivatives formed from co-mutagenic action of β-carbolines and aniline and o-toluidine and its effect on tumorigenesis in humans: A review

Norharman exists in cigarette smoke and cooked foods and is non-mutagenic among Salmonella strains but mutagenic to S. typhimurium TA98 and YG1024 in the presence of S9 mix and aniline and o-toluidine. Co-mutagenesis of β-carbolines and aniline and o-toluidine occurs through the formation of novel mutagenic aminophenyl-β-carboline derivatives including 9-(4’-aminophenyl)-9H-pyrido[3,4-b]indole [aminophenylnorharman] (APNH)] and 9-(4’- amino-3’-methylphenyl)-9H-pyrido[3,4-b]indole [aminomethylphenylnorharman] (AMPNH)]. Since humans are often simultaneously exposed to β-carbolines and aniline and o-toluidine, their effects on humans should be clarified. The most potent of these, APNH, induced both point mutations and small deletions in the liver and colon of gpt delta transgenic mice. Major APNH-induced mutations in the liver occurred at a G:C base pair, suggesting that APNH-DNA adducts (dG-C8-APNH) are potentially involved in these mutations. Furthermore, APNH induced hepatic and colon tumors harboring K-ras, β-catenin, and Apc mutations in F344 rats, with high incidence. Mutations at G:C base pairs were predominant, similar to those in the in vivo mutation assay using gpt delta mice. Moreover, APNH detected in human urine samples obtained from both healthy volunteers on a normal diet and inpatients receiving parenteral alimentation; therefore, APNH can be considered an endogenous carcinogen contributing to tumorigenesis. Exposure levels of these aminophenyl-β-carboline derivatives may be lower than those of carcinogenic heterocyclic amines (HCAs) including 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) and 2-amino-3,8-dimethylimidazo[4,5-f]quinoxaline (MeIQx); however, their health risks in terms of tumorigenesis may be comparable owing to stronger genotoxic effects of APNH rather than HCAs. This review summarized APNH mutagenicity/carcinogenicity, and its in vivo formation. Moreover, the effect on tumorigenesis in humans also discussed.

Anaesthetic management of acute abdomen: a clinical study

Background: Patients of acute abdomen present anaesthetic problems like fluid and electrolyte loss, intraoperative vomiting, regurgitation and aspiration, postoperative sickness, electrolyte imbalance, prolonged total parenteral alimentation etc. This study focused on intraoperative and postoperative complications with reference to anaesthetic management.Methods: Around 300 patients, suffering from acute abdomen, operated during routine or emergency were randomly distributed in three groups, Group I General anaesthesia with narcotic analgesics and relaxants; Group II General anaesthesia with inhalational agents; Group III Spinal subarachnoid analgesia. No modification of pre and post-operative hospital care and treatment was done.Results: There was a preponderance of younger age group patients (15 to 34years), more often in male patients. The mean duration in Group I was highest. Intraoperative Hypotension was the commonest (86 patients) followed by regurgitation and aspiration. Post-operative pyrexia was the commonest complication (120 patients) followed by postoperative nausea. ASA Grade III had a mortality of 22 patients (11.6%), ASA Grade IV having mortality of 46 patients (60.52%). About 221 patients had long duration of operations and the mortality was 28.95% as compared to 79 patients operated for short duration having mortality of 13.92%.Conclusions: Outcome and the survival of the patients depend on the surgical disease, duration of surgery, preoperative ASA grading, degree of dehydration, and the anaesthetic technique.

Early Total Enteral Feeding in Stable Very Low Birth Weight Infants: A Before and After Study.

Fear of necrotizing enterocolitis (NEC) has perpetuated delayed initiation and slow advancement of enteral feeding in very low birth weight (VLBW) infants with inherent risks of parenteral alimentation. The objective of this study was to assess effect of early total enteral feeding (ETEF) on day of achievement of full enteral feeds, feed intolerance, NEC and sepsis. In total, 208 stable VLBW neonates (28-34 weeks) admitted during 6 month periods of three consecutive years were enrolled. First phase (n = 73) constituted the 'before' phase with standard practice of initial intravenous fluid therapy and slow enteral feeding. The second prospective phase (n = 51) consisted of implementation of ETEF with infants receiving full enteral feeds as per day's fluid requirement since Day 1 of life. The third phase (n = 84) was chosen to assess the sustainability of change in practice. Day of achievement of full feeds was significantly earlier in Phases 2 and 3 compared with Phase 1 (8.97 and 5.47 vs. 14.44 days, respectively, p = 0.0001). Incidence of feed intolerance was comparable between Phases 1 and 2 (22 vs. 14%, p = 0.28), with marked reduction in incidence of NEC (14 vs. 4%, p = 0.028). There was a significant decrease in sepsis, duration of parenteral fluid and antibiotic therapy as well as hospital stay with comparable mortality. In stable preterm VLBW infants, ETEF is safe and has the benefit of optimizing nutrition with decrease in sepsis, NEC and hospital stay.

Application and choice of different intravenous infusion methods for parenteral nutrition in patients with advanced gastric cancer

Objective To evaluate the effects of three intravenous infusion modes (disposable venous indwelling needle, central venous catheter, and peripherally inserted central catheter) in patients with advanced gastric cancer for parenteral nutrition. Methods A total of 180 patients with parenteral alimentation were divided into three groups. Patients in group A were disposable venous indwelling needle, but patients in group B with central venous catheterization (CVC catheterization) and patients in group C with peripherally inserted central catheter (PICC transfusion) . Merits and demerits were evaluated in three groups via observing the index of cannula success rate, phlebophlogosis, indwelling time, etc. Results Average indwelling time of three intravenous infusion modes were not identical, and the group PICC catheter time was the longest; although there was no statistical difference in complication incidences (P>0.05) , but the group of CVC and PICC patients with phlebitis situation were better than that of indwelling needle group, and complications were also less than needle group. Conclusions High occurrence rate of phlebophlogosis exists in using disposable venous indwelling needle, which leads to short indwelling time. Risks of deep venous thrombos and infection may happen with the CVC, while come with the longer indwelling time and lower occurrence rate of the phlebophlogosis as well. PICC cost higher, while come with the longer indwelling time and lower occurrence rate of phlebophlogosis. It is suitable for the patients with long-term venous transfusion. Key words: Parenteral nutrition; Stomach neoplasms; Intravenous infusion

Defects in myosin VB are associated with a spectrum of previously undiagnosed low γ-glutamyltransferase cholestasis.

Hereditary cholestasis in childhood and infancy with normal serum gamma‐glutamyltransferase (GGT) activity is linked to several genes. Many patients, however, remain genetically undiagnosed. Defects in myosin VB (MYO5B; encoded by MYO5B) cause microvillus inclusion disease (MVID; MIM251850) with recurrent watery diarrhea. Cholestasis, reported as an atypical presentation in MVID, has been considered a side effect of parenteral alimentation. Here, however, we report on 10 patients who experienced cholestasis associated with biallelic, or suspected biallelic, mutations in MYO5B and who had neither recurrent diarrhea nor received parenteral alimentation. Seven of them are from two study cohorts, together comprising 31 undiagnosed low‐GGT cholestasis patients; 3 are sporadic. Cholestasis in 2 patients was progressive, in 3 recurrent, in 2 transient, and in 3 uncategorized because of insufficient follow‐up. Liver biopsy specimens revealed giant‐cell change of hepatocytes and intralobular cholestasis with abnormal distribution of bile salt export pump (BSEP) at canaliculi, as well as coarse granular dislocation of MYO5B. Mass spectrometry of plasma demonstrated increased total bile acids, primary bile acids, and conjugated bile acids, with decreased free bile acids, similar to changes in BSEP‐deficient patients. Literature review revealed that patients with biallelic mutations predicted to eliminate MYO5B expression were more frequent in typical MVID than in isolated‐cholestasis patients (11 of 38 vs. 0 of 13). Conclusion: MYO5B deficiency may underlie 20% of previously undiagnosed low‐GGT cholestasis. MYO5B deficiency appears to impair targeting of BSEP to the canalicular membrane with hampered bile acid excretion, resulting in a spectrum of cholestasis without diarrhea. (Hepatology 2017;65:1655‐1669).

Microvillus inclusion disease: a subtotal enterectomy as a bridge to transplantation

Background: Microvillus inclusion disease (MVID) is a known congenital cause of intractable diarrhea resulting in permanent intestinal failure. There is need for a lifelong total parenteral nutrition (TPN) from diagnosis and the prognosis is poor. Most patients die by the second decade of life as a result of complications of parenteral alimentation including liver failure or sepsis. The only available treatment at this moment is a small bowel transplantation. But before that moment, the patients often suffer from a persistent failure to thrive and electrolyte disturbances despite continuous TPN.Methods and Results: We report what we believe is a first case of an extensive small bowel resection in a 5-month-old boy with proven MVID to act as a bridge to (liver-) intestinal transplantation to treat failure to thrive and intractable diarrhea.Conclusions: An extensive small bowel resection can be done to enhance the chance of survival leading up to the transplantation by managing fluid and electrolyte imbalance. It facilitates medical management of these patients and makes a bowel transplantation possible at a later stage.

Treatment difficulties of malignant esophagorespiratory fistula: Case report of a 56-year-old patient with esophageal cancer

Abstract Introduction An esophagorespiratory fistula (ERF) is a lethal complication of advanced esophageal cancer. The preferred treatment method is placing a self-expanding stent, which is expected to decrease the risk of life-threatening complications. Aim In the case study we present a patient with esophageal cancer complicated with the presence of ERF, pneumonia, lung abscess and severe malnutrition. Case study A 56-year old man was hospitalized due to short syncope, dyspnea and cough. Cachexia was apparent. Immediate diagnostics with chest X-ray, bronchoscopy, gastroscopy and computed tomography (CT) of the chest revealed esophageal cancer and presence of ERF with respiratory complications. Endoscopic stent placement significantly decreased the initial symptoms. The patient was later re-admitted due to recurrent respiratory infections, dysphagia and progressing cachexia. He required stent placement again, parenteral alimentation and prolonged antibiotic therapy. From the diagnosis he survived 28 weeks. Results and discussion The average survival of patients with diagnosed ERF is about 8 weeks. The palliative treatment is expected to reduce bronchial aspirations and to prevent dysphagia. The recommended method is the insertion of esophageal stent to unblock the gastrointestinal tract and to close the fistula simultaneously. Reopening of the ERF is a severe complication caused mostly by progressing neoplasm. Successful surgical treatment of primary or recurrent fistulas is only probable in patients with good or moderate performance status. Conclusions An immediate implementation of diagnostic and therapeutic methods is necessary, as the time to diagnosis and treatment of a malignant fistula strongly influences the patient's survival and quality of life.

Full-thickness esophageal perforation after fluoroscopic balloon dilation: incidence and management in 820 adult patients.

The purpose of this study is to investigate the incidence, management, and outcomes of esophageal perforation after fluoroscopic balloon dilation in 820 adult patients with esophageal diseases. Between December 1990 and April 2014, a total of 820 adult patients (age range, 21-93 years) underwent 1869 fluoroscopic balloon dilation sessions (mean, 2.3 sessions/patient; range, 1-29 sessions/patient) for esophageal diseases. We retrospectively reviewed the prospectively collected medical records and images of these patients and collected the data of patients who developed esophageal perforations after fluoroscopic balloon dilation. During this period, 12 patients (six men and six women; mean age, 51 years; age range, 28-69 years) developed perforations. The perforation rate was 1.5% per patient and 0.6% per dilation. Among the first eight patients, four who were treated with surgery had perforations 2 cm or larger, and the other four who underwent fasting, parenteral alimentation, and treatment with antibiotics had perforations smaller than 2 cm. The last four patients underwent stent placement immediately after the diagnosis, regardless of the perforation's size. The median hospital stay was 11.5 days. Fluoroscopic balloon dilation of esophageal diseases is a safe procedure with a low perforation rate. A perforation size greater than 2 cm is considered large and requires aggressive treatment. Although the number of patients with esophageal perforation we treated is relatively small and further clinical trials are needed, temporary stent placement seems to be an initial choice in the management of esophageal perforations after fluoroscopic balloon dilation.

A Clinical Risk Model for the Evaluation of Bronchopleural Fistula in Non-Small Cell Lung Cancer After Pneumonectomy

There are no reliable risk factors to predict bronchopleural fistula (BPF) formation in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC). This study aims to create a validated clinical model based on the risk factors for BPF after pneumonectomy. The model to estimate the risk of BPF may help select patients for intervention therapy to reduce the rate of BPF after pneumonectomy. This retrospective analysis included 684 patients with NSCLC who underwent pneumonectomy at our institution from 1995 to 2012. The rates of BPF were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for the BPF and based on which a clinical model for the prediction of the incidence of BPF was formed. The incidence of BPF was 4.4% (30 of 684 patients). Three factors were independently associated with BPF after pneumonectomy for NSCLC: neoadjuvant therapy (hazard ratio, 2.479), diabetes mellitus (hazard ratio, 1.061), and age 70 years or older (hazard ratio, 1.175). A scoring system for BPF was developed by assigning 2 points for a major risk factor (neoadjuvant therapy) and 1 point for each minor risk factor (diabetes mellitus and age ≥ 70 years). The 684 patients were divided into a low-risk group (score, 0 to 1), moderate-risk group (score, 2), and high-risk group (score, ≥ 3), with respective incidences of early BPF after pneumonectomy of 2.4%, 18.2%, and 58.3% This model, based on readily available clinical characteristics, can estimate the risk of BPF after pneumonectomy in the NSCLC patients, independent of early BPF and late BPF classifications. This model could be used to select patients for intervention therapy (parenteral alimentation, control of blood glucose level, oxygen therapy, and strengthening the antibiotic treatment) if validated in independent data sets.

Iatrogenic Duodenal Perforation Treated with Endoscopic Placement of Metallic Clips: A Case Report

Perforation is one of the major complications encountered during endoscopic procedures. The standard of care for these complications is either surgical intervention or nonoperative medical approach with antibiotics and bowel rest with or without parenteral alimentation. Metallic clips, initially developed to secure hemostasis in bleeding, have been successfully used to close perforations in the gastrointestinal tract (GI) including the duodenum. This avoids perioperative morbidities associated with surgical intervention while limiting the leakage of intestinal contents and peritoneal contamination that is possible with medical management. We present a case of a patient with a lateral duodenal perforation during an endoscopic retrograde cholangiopancreatography (ERCP) which was successfully treated with immediate placement of metallic endoclips.

Phrenic nerve injury due to thoracentesis for TPN effusion in a preterm newborn: consecutive two unusual complications

Central venous catheters ara commonly used in neonatal intensive care units as routes of parenteral nutrition. Pleural effusions caused by extravasation of parenteral alimentation fluid are a rare complication of central venous catheters in the newborn. Diaphragmatic paralysis due to phrenic nerve injury is a rare respiratory condition which may be life-threatening in infants.

Risk factors and pathogen profile of ventilator‐associated pneumonia in a neonatal intensive care unit in China

The aim of the present study was to explore the incidence and risk factors of, and summarize the involved pathogens in, neonates with ventilator-associated pneumonia (VAP) in the authors' neonatal intensive care unit (NICU) to determine the effective strategies for prevention. A retrospective case-control study including 117 VAP patients and 232 controls was conducted from January 2002 to July 2008. The antibiotics sensitivity spectrum was determined on quantitative microbiological evaluation. Multiple logistic regression and Cox model analysis were performed to determine independent and accumulative risk factors for VAP. Multivariate analysis showed that birthweight, mechanical ventilation (MV), parenteral alimentation, dexamethasone and other respiratory disease were associated with the development of VAP. The cumulative risk for developing VAP increased over the duration of stay in the NICU. The most common isolated bacteria of the pathogen spectrum in VAP were Klebsiella spp. (33/146), Acinetobacter baumannii (26/146), Pseudomonas aeruginosa (18/146) and Staphylococcus aureus(13/146). Meanwhile, we found that previous use of antibiotics before VAP diagnosis was not associated with the onset of VAP. The daily risk for VAP increases with duration of stay in the NICU after ventilation. Drug-resistant bacteria are common pathogens for neonatal VAP in the authors' NICU.

Shoshin beriberi mimicking central line sepsis in a child with short bowel syndrome

Shoshin beriberi, cardiac failure secondary to a severe deficiency of the vitamin thiamine, can develop in patients following extensive intestinal resection or bypass; however, parenteral supplementation has largely eliminated this complication. Hemodynamic instability resulting from central line sepsis is a far more common complication in these parenteral nutrition-dependent patients. This case report details the diagnosis and treatment of shoshin beriberi in a patient with short bowel syndrome whose presentation mimicked central line sepsis. A retrospective chart review was performed. Appropriate laboratory data were included. The patient was treated unsuccessfully with antibiotics and supportive measures. Resolution of symptoms was achieved only after the empiric administration of thiamine and folate. This case highlights that life-threatening thiamine deficiency mimicking septic shock can develop in patients with short bowel syndrome, despite oral multivitamin administration. We recommend diligent monitoring of vitamin levels in any total parenteral alimentation dependent patient unable to receive the intravenous multivitamin complex, regardless of oral vitamin supplementation or clinical findings.

Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement

Purpose Seven metrics of metabolic derangement were evaluated as contributors to clinical decision support for operative intervention in infants with suspected necrotizing enterocolitis (NEC). Methods Records of infants with suspected NEC without radiologic evidence of free air were queried for presence of 7 components of metabolic derangement (CMD), consisting of positive blood culture, acidosis, bandemia, thrombocytopenia, hyponatremia, hypotension, or neutropenia. Cases were stratified by clinical decision after each surgical evaluation as observation (OBS) or intervention (INT). Good outcome was defined as full enteric feeding by discharge and bad outcome as death or ongoing parenteral alimentation. Eleven infants undergoing operative intervention after an initial decision to observe were evaluated as matched pairs. Components of metabolic derangement/case and frequency of each CMD were determined for OBS and INT. Mann-Whitney U test was used to compare proportions of CMD in each group. Outcome was compared using χ 2. Observation was then stratified by outcome to determine whether 3 or more metabolic derangements warranting operative intervention would have changed initial clinical decision. The 11 matched cases were similarly analyzed using Wilcoxon-matched pairs. Results Between March 2005 and July 2008, 35 infants with NEC received 53 surgical evaluations. A median of 1 CMD/case was defined in 32 instances of OBS. Surgical intervention was carried out in 19 infants with a median of 3 CMD/case. Mann-Whitney U test indicated significant difference in the frequencies of each CMD component in OBS vs INT ( P = .04). Good outcome was achieved in 75% of OBS and 63% of INT (non-significant, NS). Analysis of OBS by outcome demonstrated a median 1 CMD/case of 25 with good outcome and 3 CMD/case in infants with bad outcome. Frequency of CMD was significantly higher in infants with bad outcome ( P = .02). Wilcoxon-matched pair analysis of the 11 infants with paired evaluations demonstrated a similar distribution and frequency of CMD. Conclusion Progressive metabolic derangement of infants with NEC can be clinically tracked. The appearance of any 3 of these 7 metrics indicates timely operative intervention. Application of CMD trajectory to timing of surgical intervention may improve outcome and define the relationship between specific CMD and operative risk.

POTASSIUM and parenteral protein alimentation.

POTASSIUM and parenteral protein alimentation.