Small Sips Research Articles

Utility of smart watch in expediting diagnosis of cold drink-triggered atrial fibrillation: a case report

BackgroundPatients presenting to the emergency department with recent palpitations are a diagnostic challenge when the arrhythmia and its symptoms have resolved prior to arrival. Newer smart watch technology, adept at detecting atrial fibrillation, can assist in the diagnostic evaluation of transitory palpitations. We report a case of cold drink-triggered atrial fibrillation whose diagnosis would not have been possible without the assistance of the patient’s smart watch.Case presentationA middle-aged man without cardiac history developed sudden rapid, irregular palpitations with shortness of breath while drinking a glass of cold juice. He activated his smart watch with 1-lead electrocardiography technology which detected rapid atrial fibrillation. He sought medical care, but while waiting, his symptoms—then 90 min in duration—spontaneously resolved. His initial diagnostic evaluation documented only sinus rhythm, as did several follow-up evaluations with cardiology the next several weeks. Had it not been for his smart watch, the etiology of his transitory palpitations would have remained undiagnosed. His physicians encouraged trigger avoidance. In the following months, he avoided rapid ingestion of cold drink, taking instead small sips. The atrial fibrillation has not recurred.ConclusionsThe case illustrates the valuable contribution of smart watch technology in the diagnostic evaluation of patients with short-lived palpitations. The case also educates clinicians about cold drink and food as a trigger of paroxysmal atrial fibrillation. This trigger, like alcohol, can be modified. Cold drink trigger avoidance has been reported by patients to reduce atrial fibrillation recurrence and is a low-risk, cost-effective strategy that is often successful.

Resolution of severe gastroparesis induced by parasympathetic surge following facial trauma: a case report

BackgroundGastroparesis is a condition that affects the motility of the gastrointestinal (GI) tract, causing a delay in the emptying process and leading to nausea, vomiting, bloating, and upper abdominal pain. Motility treatment along with symptom management can be done using antiemetics or prokinetics. This study highlights the diagnostic and therapeutic challenges of gastroparesis and suggests a potential link between facial trauma and symptom remission, indicating the need for further investigation.Case presentationA 46-year-old Hispanic man with hypertension, type 2 diabetes (T2D), and hyperlipidemia on amlodipine 10 mg, lisinopril 5 mg, empagliflozin 25 mg, and insulin glargine presented with a diabetic foot ulcer with probable osteomyelitis. During hospitalization, the patient developed severe nausea and vomiting. The gastroenterology team advised continuing antiemetic medicine and trying very small sips of clear liquids. However, the patient didn’t improve. Therefore, the gastroenterology team was contacted again. They advised having stomach emptying tests to rule out gastroparesis as the source of emesis. In addition, they recommended continuing metoclopramide, and starting erythromycin due to inadequate improvement. Studies found a 748-min stomach emptying time. Normal is 45–90 min. An uneventful upper GI scope was done. Severe gastroparesis was verified, and the gastroenterology team advised a percutaneous jejunostomy or gastric pacemaker for gastroparesis. Unfortunately, the patient suffered a mechanical fall resulting in facial trauma. After the fall, the patient’s nausea eased, and emesis stopped. He passed an oral liquids trial after discontinuation of erythromycin and metoclopramide.ConclusionThis case exemplifies the difficulties in diagnosing and treating gastroparesis. An interesting correlation between parasympathetic surges and recovery in gastroparesis may be suggested by the surprising remission of symptoms following face injuries.

An Analysis of Fluid Intake Assessment Approaches for Fluid Intake Monitoring System.

Monitoring fluid intake is essential to help people manage their individual fluid intake behaviors and achieve adequate hydration. Previous studies of fluid intake assessment approaches based on inertial sensors can be categorized into wrist-worn-based and smart-container-based approaches. This study aims to analyze wrist-worn-based and smart-container-based fluid intake assessment approaches using inertial sensors. The comparison of these two approaches should be analyzed according to gesture recognition and volume estimation. In addition, the influence of the fill level and sip size information on the performance is explored in this study. The accuracy of gesture recognition with postprocessing is 92.89% and 91.8% for the wrist-worn-based approach and smart-container-based approach, respectively. For volume estimation, sip-size-dependent models can achieve better performance than general SVR models for both wrist-worn-based and smart-container-based approaches. The improvement of MAPE, MAD, and RMSE can reach over 50% except MAPE for small sip sizes. The results demonstrate that the sip size information and recognition performance are important for fluid intake assessment approaches.

Unrestricted drinking before surgery: a structured patient interview.

Our recent study [1] showed that unrestricted drinking before surgery, and its implementation using fasting cards, shortened the median pre-operative liquid fasting time to 2.1 h. Although adherence to the guidelines was significantly improved, critics questioned whether patients drink too much liquid immediately before induction of anaesthesia. Therefore, we evaluated our study data regarding patients' drinking behaviour. In the third PDSA cycle [1], 25 weeks after the implementation of fasting cards, 143 patients underwent a structured interview. The results are summarised in Table 1. On the day of surgery, 130 (91%) patients had drunk at least 100 ml of liquid or at least 2 ml.kg−1 if they were children. The minimum time interval between drinking clear liquids and induction of anaesthesia was 25 min (Fig. 1). The median (IQR [range]) volume of the last liquid intake before induction of anaesthesia was 200 (150–250 [50–500]) ml. Patients were asked about the total amount drunk on the day of surgery. Of 108 patients, six had not drunk anything at all, two patients had only taken a few sips with their morning medication and two infants had drunk 50 ml each. Of the remaining 98 patients, the median (IQR [range]) pre-operative cumulative drinking volume was 400 (200–500 [100–1500]) ml, and was higher when anaesthesia was induced later in the day. Patients with induction of anaesthesia before 11.00 (n = 44) had drunk a median (IQR [range]) of 250 (200–363 [100–500]) ml, while patients with induction of anaesthesia after 11.00 (n = 54) had drunk a median (IQR [range]) of 500 (400–750 [100–1500]) ml; p < 0.0001. Regarding drinking quantities, patients drank small amounts repeatedly, hence the pre-operative total liquid intake increased as the day went on. Patients who usually drink little and may still be worried about urinary urgency also drink little pre-operatively. For them, small sips are enough to reduce thirst and dry mouth [2]. Thus, the lowest pre-operative cumulative drinking volume at anaesthetic induction, both before and after 11.00, was 100 ml. Other patients liked to drink more during the day; the largest cumulative total when anaesthetic induction was after 11.00 was 1500 ml, which was three times the largest cumulative total when anaesthetic induction was before 11.00 (500 ml). For elderly patients in particular, it is important to drink in the morning; these patients consume about 60% of their daily liquid intake between 05.00 and 13.00 and another 30% until 19.00. They might intentionally avoid drinking in the evening because they are concerned regarding night-time incontinence [3]. Therefore, the risk of peri-operative dehydration in this group is relatively high. Prolonged deprivation of fluids harms patients [4], but forcing them to drink more than they want to, for example in the context of studies with rigid drinking instructions, makes them uncomfortable. Patients who drank an amount they were used to had less anxiety [2], and anxiety regarding their operation is the most troublesome aspect for many patients [5]. Unrestricted drinking before surgery allows patients to drink on the day of surgery in the manner they are used to and find comfortable. Therefore, only 3.5% of our study patients reported severe thirst, even though thirst appears to be the most frequent feature of peri-operative discomfort [5]. Unrestricted intake of clear liquids before induction of anaesthesia has been shown to reduce the incidence of postoperative nausea and vomiting [6, 7], a predictor of patient dissatisfaction with anaesthesia [7, 8]. Only 2.8% of our patients required an anti-emetic in the recovery room. Our study has some limitations. In the interviews, the patients were able to state the time of the last liquid intake very precisely. However, the amount of liquid last drunk sometimes referred to a time-period rather than a time-point. Thus, the last amount of liquid consumed may have been overestimated. Data on the total amount drunk on the day of surgery were not available for 35 patients as this question was only added to the interview on the second day of the survey. In summary, patients were allowed unrestricted drinking before surgery, drank wisely and according to their needs. The amount and type of liquid desired were highly individual. This liberal liquid regime may prevent peri-operative anxiety, stress, postoperative nausea and vomiting, postoperative delirium and other complications. No competing interests declared. Open Access funding enabled and organized by Projekt DEAL.

Tea Mind: Living the Way of Tea

Tea MindLiving the Way of Tea Solala Towler (bio) When we drink the tea, we need to slow down and feel the different kinds of energy in each small sip of tea with different parts of the mouth and the heart. —Zhongxian Wu My partner Shanti and I often invite friends over for tea. We find it a more simple, less complicated thing than inviting them over for dinner. We have tea and snacks and often spend hours visiting. Yet our tea party is a little different than what most people are used to. Our type of tea is called gongfu cha 功夫茶. Gongfu is one of those misunderstood terms in Chinese that most people associate with martial arts (wushu 武術). It actually means anything that you study (time and effort) and get good at. It can be gongfu gardening, gongfu painting and yes, gongfu martial arts. Another name for what we are doing here is pinming lundao 品茗論道 or "savor tea, discuss Dao." Usually, when we talk about drinking tea we would say hecha 喝茶 but here we use a different term, pin. Pin means something more than just drinking tea. The character for pin is made up of three squares, which represent three mouths, as in the three sips we take at the beginning of the ceremony. Not only that, but it has a quality of savoring or going slowly and really letting not only the flavor of the tea, but the energy of the tea, to enter our being in a deep way. The next character, ming, means high quality tea or a special kind of tea. This can be an expensive tea or just one that carries a lot of meaning for us. In this way, we are offering our guests much more than just a cup of tea. We are sharing something deep and profound. The last two characters, lundao, refer to lifting the conversation into the realm of philosophy or some other high-minded conversation. I find when I do Daoist gongfu tea ceremonies that the tea really opens people [End Page 176] up to better able to grasp the Taoist teachings that I share as well. There is just something that is relaxing yet also stimulating about this simple ceremony. The type of tea most gong fu tea practitioners use is called Puerh 普洱. This kind of tea has been used for many hundreds, if not thousands of years for tea self-cultivation practice. It grows in trees, high in the mountains of Southwest China, in Yunnan province. The tea trees can be hundreds of years old, and have roots growing hundreds of feet into the earth. Puerh tea is a fermented tea, so it has lots of good qualities for our digestion, and is low in caffeine, among other wonderful attributes. This kind of tea is often pressed into cakes and you need to break them open in order to drink the tea. But, by being pressed this way, the tea will last a very long time without going bad. There are actually two kinds of Puerh. One is naturally fermented over a long time, called "raw" (sheng 生). And one that is quickly fermented called "cooked" (shou 熟). Each one of them has its own characteristics. The aged sheng versions can cost thousands of dollars, just like finely aged wine (see Towler 2010). But really, you can use any kind of tea you like. The practice is the same. The attitude we bring to the ceremony is really the most important part. So, we put a measure of tea into the pot, let is steep for just a few minutes and then pour it out as well. This is called "washing the leaves" and gets rid of any dust left on the leaves. I also call it "waking up the leaves." It allows the flavor and goodness of the leaves to really open and improves the flavor of the tea. Then we let it steep a few moments more and pour it into the small cups. We pick up the cups, holding them with our thumb and first finger on the sides with ring finger on the bottom, and align them with our heart so that the...

Does What I Say Matter? Influence of Verbal Instruction on Bolus Size: Pilot Data

<h3>Research Objectives</h3> To evaluate the effects, if any, verbal instructions and delivery method may have on bolus size with self-administration of thin liquids. <h3>Design</h3> Prospective, randomized, repeated measure study. <h3>Setting</h3> Freestanding rehabilitation hospital. <h3>Participants</h3> Convenience sample of healthy adults with no history of dysphagia. <h3>Interventions</h3> Subjects were randomized into either the cup or straw group. Each subject consumed eight boluses of water under four different instructions: 1) Take a drink; 2) Take a comfortable sip; 3) Take a small sip: 4) Take a small sip like it is hot coffee. Order of instructions was randomized. Each subject had eight cups prepared (4 cups 60-ml water in 120-ml cup; 4 cups120-ml water in 240-ml cup). Subjects received new cup for each drink instruction. Ratio of liquid to cup size was the same between two cup sizes. <h3>Main Outcome Measures</h3> Bolus size extrapolated from weight of cup / water before and after each administration. <h3>Results</h3> Ten healthy subjects (5 men; 5 women), age range 22-58 years, mean age 39.3 years (SD=11.4 years) participated in the study. Overall, the differences between the mean volume consumed using various instructions were statistically significant (take a drink=28.80 ml; comfortable sip=14.35 ml; small sip=5.3 ml; small sip like it is hot coffee=3.01 ml; F=22.51, p≥.0001). Differences in mean volume consumed by cup size (i.e., 4-ounce cup vs. 8-ounce cup) were not statistically significant (p=.581). Differences in mean volume consumed by straw or cup presentation were not statistically significant (p=.914). <h3>Conclusions</h3> Results suggest verbal instruction has an influence upon bolus size with healthy adults with the semantic cue instruction (hot coffee) resulting in the lowest volume consumed. No differences were observed in amount consumed by cup size or straw vs. cup presentation. Reducing bolus size is a common clinical strategy to eliminate or reduce aspiration. It is important for the dysphagia rehabilitation team to understand the influence verbal instructions may have upon bolus size to facilitate a safe swallow. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interests to disclose.

Acute perchloroethylene intoxication in an elderly woman: a case report

BackgroundPerchloroethylene is a colorless, strong-smelling substance commonly used for dry cleaning. Liver and kidney toxicities and carcinogenicity are well-known occupational hazards caused by chronic perchloroethylene exposure. Acute intoxication by ingestion of nondiluted perchloroethylene is rare in the adult population owing to its strong smell and taste. Very few data are available to physicians managing patients in this situation.Case presentationAn 89-year-old Caucasian woman accidentally drank perchloroethylene while visiting her laundry, leading to a coma within a few minutes. The poison control center provided little information about perchloroethylene toxicity after ingestion, including an estimated long biological half-life (144 hour) and detrimental effects to liver and kidneys. A long intensive care unit stay was thus expected, potentially leading to several complications. After intubation, transitory hypoxemia appeared and rapidly resolved, while mild hemodynamic instability was managed with fluid resuscitation and anti-arrhythmic drugs. Twelve hours after perchloroethylene ingestion, the patient suddenly woke up and self-extubated. Less than 24 hours after ingestion, she was discharged from the intensive care unit, and 4 days later she was discharged home.ConclusionThe patient drank perchloroethylene from a bottle, which prevented her from smelling it, and owing to its taste, only a small sip was likely drunk. However, a much larger intake was presumed, given her rapid and profound central nervous system depression. This case was challenging owing to the paucity of information available regarding acute perchloroethylene ingestion and the duration and magnitude of its effect. The present report will hopefully be of support for clinicians managing patients with this rare acute intoxication.

US EPA green-lights paraquat

The acutely toxic herbicide paraquat can stay on the US market with new safety measures to reduce farmworker exposures, the Environmental Protection Agency says in an interim decision announced Aug. 2. The decision comes as the pesticide’s manufacturer Syngenta and distributor Chevron Phillips Chemical face more than 100 lawsuits from agricultural workers who claim that exposure to paraquat contributed to their Parkinson’s disease. The EPA acknowledges the acute toxicity of paraquat, stating on its website , “One small sip can be fatal and there is no antidote.” But the agency dismisses several scientific studies that link paraquat exposure to Parkinson’s disease, claiming the studies vary in quality and provide conflicting results. Under the Trump administration, the EPA proposed banning most aerial spraying of paraquat. But after reviewing data from the pesticide industry, the agency now says aerial applications are allowed with some restrictions, including no-spray buffers in residential areas. Other

Wild Swims: Stories by Dorthe Nors

BOOKS IN REVIEW looks out at “the friendly, broken, undulating landscape, so far from the fucking metaphysical pampa of Argentina.” The buildings of Montevideo, familiar yet oldfashioned and exotic, soothe him, and he begins to shake free from the weight of his life as a broke writer and stay-at-home dad, stuck in a “paralyzed” relationship with his wife, Catalina. Not surprisingly, there also happens to be another woman involved: Magalí Guerra Zabala, twenty-eight, “the woman from Uruguay,” whom he fell for at a beachside literary festival months before and is planning to rendezvous with in the Uruguayan capital. He can barely contain his anticipation: “I was in love with a woman and in love with the city where she lived. And I made up everything about it, or almost everything. An imaginary city in an adjacent country. That was where I walked, more than down real streets.” The Woman from Uruguay gathers momentum and sparks as Lucas and Magalí eventually meet up at an outdoor café and plot their afternoon seduction over multiple rounds of drinks. Inevitably, though, their plans go awry, and the day takes on a sinister, hallucinatory edge— involving a trip to a tattoo parlor, possible UFO sighting, snarling pit bull, and angry ex-boyfriend—before finally erupting in violence. Has Lucas been deceived all along by Magalí, lured by Montevideo’s laid-back charm (and public pot-smoking)? Has he been set up, an easy target for street thugs with his pockets for once full of cash? “You have to be careful with Montevideo,” a friend admonishes him. “Montevideo will kill you without a second thought. Every now and then it does, just lays somebody out.” Mairal, himself an acclaimed and bestselling Argentine author, has written a gripping adventure novel of the mind— rendered in pulsating prose by Jennifer Croft—of a middle-aged writer’s delusions and spiraling collapse. But even after Lucas hits rock-bottom, he’ll discover new, truer ways of being both a father and writer. “I’m working on a book of poems, and, very slowly, another novel,” he later explains, “but no Amazonian adventures, no narcos or gunfights or knives, just a few kicks on the other side of the river.” Crossing the River Plate has had a profound effect on Lucas, and nothing will be the same again. Anderson Tepper New York Dorthe Nors Wild Swims: Stories Trans. Misha Hoekstra. Minneapolis. Graywolf Press. 2021. 128 pages. WILD SWIMS, the second short-story collection by Danish author Dorthe Nors, makes its US debut with fourteen minitales , nine brand-new. Ranging from four to seven pages, the stories are small sips ending in dark rum punches. The book appeared in Denmark as Kort over Canada in 2018. Settings range from Sydvest, Minneapolis , Los Angeles, Manitoba, New York, London, and Norway to Denmark. Scenes capture feelings that elude a camera lens, unveiling inner motivations. Voices shift effectively, with some in first person, others in third. Most pieces convey remoteness, in landscape as well as character. Even in large cities there’s a bareness. People neither exude joy nor connect with one another. Nors teases at times with a cozy beginning, but eventually the murky underbelly emerges. Hygge, that Danish sense of coziness, never lasts long. In fact, the aptly titled “Hygge” is a good example. The initial, contented feeling between an aging professor and a woman named Lilly slowly merges with his memories of Aunt Clara, progressing to bitterness in his mind. The tale begins with a relaxed tone: “Then we were sitting there, Lilly and me, and she had made coffee and baked one of those chocolate cakes that are soft in the middle.” Yet four pages later, it ends peevishly: “When it was all over and done, it looked as if she was forcing me, and I didn’t like it.” Nors withholds information, structuring plots out of allusions to past events not fully told—reminiscent of Ann Beattie , Raymond Carver, or William Saroyan. Nors embeds a man in a deer stand with a broken ankle but takes away his cell phone. She places a woman on a writer’s retreat near an ex-lover’s mother...

ФИЛОСОФИЯ И АРХИТЕКТУРА ЧАЙНЫХ ДОМИКОВ ЯПОНИИ

ФИЛОСОФИЯ И АРХИТЕКТУРА ЧАЙНЫХ ДОМИКОВ ЯПОНИИ

Endoscopic posterior cordotomy for treatment of dyspnea due to vocal fold immobility.

IntroductionSeveral surgical procedures have been described for the treatment of respiratory distress secondary to vocal fold immobility (VFI), but the contribution of posterior cordotomy (PC) to tracheostomy weaning or prevention has not been studied in depth, particularly in the acute setting. The objective of this study was to show the effectiveness of PC to relieve dyspnea, prevent the need for tracheostomy, and enable decannulation in patients with VFI.MethodsWe conducted a retrospective study and reviewed the medical records of all patients whose dyspnea warranted surgical intervention from January 2013 to January 2018. Data were retrieved on epidemiology, etiology, and duration of VFI, tracheostomy dependence, success in decannulation from tracheostomy or respiratory relief, number of procedures until decannulation, and complications.ResultsTwelve suitable patients were identified of whom eleven had bilateral VFI and one had unilateral VFI. Five were tracheostomy-dependent. Ten patients underwent unilateral PC, and two patients underwent bilateral PC. All the patients experienced respiratory relief, eleven after a single PC and one after two PCs. All tracheostomy-dependent patients were decannulated. The mean follow-up after PC was 24.55 months during which none of the patients required a re-tracheostomy and three patients required revision of the PC. There were no surgical complications. Postoperatively, eight patients (67%) experienced a breathy voice and three patients (25%) had dysphagia for fluids. No patient had aspiration pneumonia.ConclusionsWe conclude that PC is an easy, safe, and effective procedure for tracheostomy weaning and respiratory relief in patients with VFI. A revision PC may be indicated in some patients. A breathy voice is to be expected, and a few patients will experience dysphagia to fluids that may be addressed by instructing the patient to use a fluid thickener and take small sips.

A Deep Breath and a Small Sip.

A Deep Breath and a Small Sip.

1722 Dysphagia Lusoria Associated With Imperforate Anus

INTRODUCTION: Dysphagia lusoria is a rare intrathoracic vascular abnormality that results in the compression of the esophagus, causing dysphagia. The most common cause of dysphagia lusoria is an aberrant right subclavian artery of the aortic arch, though nearly all major arteries within the thorax have been reported to cause cause this condition. CASE DESCRIPTION/METHODS: 68-year-old male with a history of developmental delay and imperforate anus s/p colostomy and colostomy revision presented with decreased appetite, decreased ostomy output, and regurgitation of food and water. Past medical history was notable for GERD and prior small bowel obstructions. Abdominal obstructive x-ray series showed multiple nondilated gas-filled loops of small bowel. Chest x-ray showed tortuosity of the thoracic aorta. Fluoroscopic swallow evaluation showed no evidence of aspiration, and barium esophagram showed the calcified aortic arch trapping the proximal esophagus anteriorly and posteriorly, resulting in a narrowed channel with a normal appearing distal esophagus (Figure 1). CTA chest confirmed compression of the esophagus by the anomalous aortic arch (Figure 2). Multiple treatment options were considered. However, due to the patient's poor performance status and ability to tolerate small frequent sips of liquids, no surgery was pursued. The patient was discharged home in satisfactory condition. DISCUSSION: The majority of patients with dysphagia lusoria are asymptomatic and the discovery of the anomaly is often incidental. This patient had a tortuous thoracic aorta, which was known from previous imaging studies, but remained without dysphagia until this admission. The median onset of symptoms is 48-50 years; the late-onset of this condition may be due to the increased rigidity of the esophagus or calcification and atherosclerosis of the major vessels, decreasing their compliance. The presenting symptoms of dysphagia lusoria is usually progressive dysphagia, usually for solids, accompanied by regurgitation of unchewed foods, chest pain, or cough. The diagnosis is usually achieved with an initial barium esophagram, followed by CT or MRI scan. Endoscopic ultrasound with doppler is also used for diagnosis. Surgery is the preferred treatment option for symptomatic patients that can tolerate it. To our knowledge, this is the first reported case of dysphagia lusoria associated with development delay and isolated imperforate anus.

1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola

INTRODUCTION: We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia. CASE DESCRIPTION/METHODS: The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance. DISCUSSION: Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.

Періопераційне харчування як важлива ланка імплементації принципів Fast Track хірургії

ABSTRACT. Relevance. Fast Track surgery concept provides for a significant reduction of patient’s stress response to surgical intervention. The main task is a quick rehabilitation, quick return to a normal quality of life and significant reduction for an in-patient stay, thereby reducing medical costs. Objective: To assess the efficacy of the lack of pre- and postoperative fasting in accelerating postoperative recovery of patients and the reduction of patient’s stress response to operative injury. Materials and methods. We performed 564 surgical interventions under Fast Track approach. In particular, we used adapted, high-caloric sipping (drinking as small sips through a straw) feed manufactured at a medical enterprise and does not include dietary fibre — Nutricomp Drink Plus (BBraun). Results. Early oral feeding within the first hours after surgery accelerates recovery of productive intestinal motility. In 73.5 % of patients, the passage of flatus (spontaneous) is reported to the end of the first postoperative day that is about 8-fold higher than in patients who were not on such diet. General weakness, hunger and thirst reduced 2.5, 3 and 2.5-fold, respectively, in patients on Fast Track approach compared with the conventional perioperative management. Conclusion. The lack of pre- and postoperative fasting is one of the cornerstones of this program that proved the efficacy in terms of reduced stress response to surgical injury. Key Words: Fast Track approach, surgical intervention, pre- and postoperative nutrition.

The Guy

The Guy Daniel T. Durbin (bio) It had been a busy week and the return trip from Moscow, Idaho (pronounced “mos-cō” not “mos-cow,” though the locals tend to think of it as a Marxist stronghold) was always a dog-leg of flights. Worn and flight-weary, I wanted just a small sip of wine. I asked the flight attendant how much a small cup of the red would cost me. “That’s eight dollars.” On my worst day in university hell, I could never justify eight dollars for the dreck they serve on airplanes. I wasn’t going to tell her that. So, I smiled and said, “No thanks. I think I’m fine.” About twenty minutes later, the attendant returned to my seat from the back of the plane, a big smile lighting up her face, a plastic cup and a bottle of wine in her hands. “Are you working for that African American man back there? Are you his caretaker or something?” I looked back several rows. We’d been separated on this flight. But there he was, the man with the gentlest eyes I’d ever seen, an attendant kneeling in the aisle, a second one bent over his seat, all three laughing, talking, having a great time. “Well, yeah, you could say that.” She put the cup in my hand and filled it to the brim with wine. “You enjoy this and, when you’re done, you just call me back. Have as much wine as you want. Your friend is so great. We just love him. He played baseball or something, didn’t he?” “Yeah, he was a pretty good player in his day.” I held my cup of wine and turned around to see the party once again. Their laughter rang up and down the aisle. He shot me a quick glance, smiled and kept right on telling stories. “Yup,” I thought. “That’s Mudcat Grant.” Now, if you have never been a true baseball fan, then you will never get the story I have to tell. Being a middle-aged or older longtime acolyte of the game, having a room filled with autographed baseball memorabilia, or being able [End Page 28] to drop Tony Lazzeri’s lifetime triples into casual conversation with complete strangers does not make you a true baseball fan. At best, you are the ghost of a true baseball fan. Anyone who has been one knows that the true baseball fan is roughly 8–12 years of age and is not a fan of baseball. The true baseball fan is an acolyte of The Team. On that team, the true fan idolizes The Guy. An older and somewhat jaded sports scholar might aver that this should be “The Player.” But, in the kid world of true baseball fandom, this was never “The Player.” It was always “The Guy.” I was once a true baseball fan. For me, The Team was the forever frustrating and underachieving 1970 Oakland A’s. The A’s had moved to Oakland in 1968, their Kelly-green uniforms and white shoes gaudily lighting up the bay and a fleet of young talent stocking up their minor league teams. The 1970 “Swingin’ A’s” had the core set of players who would go on to become one of baseball’s great dynasties in the next half decade. But, in 1970, the entire organization was hopelessly self-destructive. A series of unnecessary mishaps kept the team firmly entrenched in second place, far behind the aging Minnesota Twins. Finding The Guy on that team was especially challenging. Reggie Jackson held out through spring training and entered the season ticked off at owner Charlie Finley (whose penny-pinching was already legendary). As a consequence, Reggie had perhaps the worst season of his long career. Joe Rudi, the steady, soon-to-be star left fielder had his fingers gruesomely crushed by an errant pitch and was out for half the season. Hall-of-Famer Rollie Fingers, two years from being a handle-bar mustachioed relief specialist, was still being uncomfortably forced into starting duties. In his infinite baseball wisdom, Finley had a revolving door of three, sometimes four, periodically...

A critical evaluation of the anabolic response after bolus or continuous feeding in COPD and healthy older adults.

After bolus and continuous enteral feeding of the same protein, different digestion and absorption kinetics and anabolic responses are observed. Establishing which mode of feeding has the highest anabolic potential in patients with chronic obstructive pulmonary disease (COPD) may aid in the prevention of muscle wasting, but an important confounding factor is the duration of assessments after bolus feeding. We hypothesized that the anabolic response to bolus and continuous feeding in COPD patients is comparable when methodological issues are addressed. Twenty-one older adults (12 patients with stage II-IV COPD and 9 healthy controls) were studied after intake of a fast-absorbing hydrolyzed casein protein-carbohydrate mixture either as a single bolus or as small sips (crossover design). Whole body protein synthesis (PS), breakdown (PB), net PS (PS - PB) protein efficiency (netPSPE), net protein balance (phenylalanine (PHE) intake - PHE hydroxylation) protein efficiency (netBalPE), and splanchnic PHE extraction (SPEPHE) were assessed using stable isotope tracer methodology. Bolus feeding assessments were done at 90, 95, and 99% of the calculated duration of the anabolic response. At 99%, netBalPE was higher for sip feeding than bolus feeding in both groups (P<0.0001). Nevertheless, bolus feeding was associated with a lower SPEPHE (P<0.0001) and higher netPSPE (P<0.0001). At 90% compared with 99%, PS and netBalPE after bolus feeding was significantly overestimated. In conclusion, several factors complicate a comparison of the anabolic capacity of bolus and continuous feeding in acute studies, including the critical role of SPE calculation and assumptions, and the duration of postprandial assessments after bolus feeding.

Pesticide Storage: Keep It in the Container

Accidents happen quickly, and so do accidents with pesticides. Anyone storing pesticides, especially in the presence of children, needs to take precautions by keeping them in their proper, original containers. Several people have died when they unknowingly drank pesticides from containers that originally held soda, other beverages, or foodstuffs. In particular, the herbicide paraquat is highly toxic to humans; one small accidental sip can be fatal, and there is no antidote. This 3-page fact sheet was written by Fred Fishel, and published by the UF Department of Agronomy, May 2015. (Photo: Fred Fishel) PI255/PI255: Pesticide Storage: Keep It in the Container (ufl.edu)

RF‐SiP Reflectometer Technology for RF Testers

SUMMARYTechnologies of small size reflectometers constructed in the form of RF functional systems in packages (SiPs) for RF testers are described. As primary concerns, focusing on the directivity and dynamic range of the reflectometer performance, we propose the construction and core circuit topologies to realize a very small reflectometer SiP that satisfies the functions of vector network analysis for RF testers. The reflectometer features a very small size, less than 1/50 of our conventional hybrid form reflectometer, and has good performance for RF testers.

Can Team-Based Medicine Prescribe Trust?

Can Team-Based Medicine Prescribe Trust?