The medical management of intestinal failure: methods to reduce the severity

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel enterocutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudoobstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90-120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and > 1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.     

Use marketing to reduce malpractice costs in health care

Marketing may have contributed to malpractice litigation by elevating public expectations. If all of the four basic functions of marketing--intelligence, strategy, operations, and communications--are applied well, then marketing may have a significant impact on malpractice risks and costs.     

Use of a clay modeling task to reduce chocolate craving

Elaborated Intrusion theory (EI theory; Kavanagh, Andrade, & May, 2005) posits two main cognitive components in craving: associative processes that lead to intrusive thoughts about the craved substance or activity, and elaborative processes supporting mental imagery of the substance or activity. We used a novel visuospatial task to test the hypothesis that visual imagery plays a key role in craving. Experiment 1 showed that spending 10 min constructing shapes from modeling clay (plasticine) reduced participants' craving for chocolate compared with spending 10 min 'letting your mind wander'. Increasing the load on verbal working memory using a mental arithmetic task (counting backwards by threes) did not reduce craving further. Experiment 2 compared effects on craving of a simpler verbal task (counting by ones) and clay modeling. Clay modeling reduced overall craving strength and strength of craving imagery, and reduced the frequency of thoughts about chocolate. The results are consistent with EI theory, showing that craving is reduced by loading the visuospatial sketchpad of working memory but not by loading the phonological loop. Clay modeling might be a useful self-help tool to help manage craving for chocolate, snacks and other foods.     

运用品管圈降低非计划性拔管发生率的实践

开展品管圈管理活动不仅降低了非计划性拔管的发生率,同时还提高了圈员的质量管理能力和积极性。     

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests

Background: Medical emergency team (MET) responses have been implemented to reduce inpatient mortality, but data on their efficacy are sparse and there have been no reports to date from US hospitals.

Objectives: To determine how the incidence and outcomes of cardiac arrests have changed following increased use of MET.

Methods: Objective criteria for MET activation were created and disseminated as part of a crisis management program, after which there was a rapid and sustained increase in the use of MET. A retrospective analysis of clinical outcomes was performed to compare the incidence and mortality of cardiopulmonary arrest before and after the increased use of MET.

Results: A retrospective analysis of 3269 MET responses and 1220 cardiopulmonary arrests over 6.8 years showed an increase in MET responses from 13.7 to 25.8 per 1000 admissions (p<0.0001) after instituting objective activation criteria. There was a coincident 17% decrease in the incidence of cardiopulmonary arrests from 6.5 to 5.4 per 1000 admissions (p = 0.016). The proportion of fatal arrests was similar before and after the increase in use of MET.

Conclusions: Increased use of MET may be associated with fewer cardiopulmonary arrests.

     

甘油三酯对大鼠重症胰腺炎内皮素和一氧化氮表达及病理评分的影响

目的探讨甘油三酯对大鼠重症胰腺炎ET-1,NO表达及病理评分的影响。方法健康SD大鼠36只,随机分为2组,每组18只。A组：高脂血症组;B组：非高脂血症组。高脂血症通过高脂饲料喂养3周形成,重症急性胰腺炎通过5％的牛黄胆酸钠逆行胰胆管注射制作。A、B两组大鼠分别于重症急性胰腺炎成模前、后4、8和12h取血测定甘油三酯、淀粉酶、ET-1和NO浓度,并取胰腺组织经HE染色病理学检查,进行胰腺病理学评分。结果B组成模后甘油三酯明显增高（P〈0．05）,A、B两组成模后各时点ET-1及NO浓度均明显增高（P〈0．05）,A组ET-1在4、8两时点增高更明显（P〈0．05）。ET-1、NO在12h时点A、B两组均呈下降趋势,以A组下降更明显。A组各时点胰腺病理学评分均明显高于B组（P〈0．05）。结论高甘油三酯条件下重症胰腺炎ET-1和NO升高更早、更加明显,高甘油三酯可加重重症急性胰腺炎胰腺的病理损害。     

Use of fly screens to reduce Campylobacter spp. introduction in broiler houses

Fly screens that prevented influx of flies in 20 broiler houses during the summer of 2006 in Denmark caused a decrease in Campylobacter spp.-positive flocks from 51.4% in control houses to 15.4% in case houses. A proportional reduction in the incidence of chicken-borne campylobacteriosis can be expected by comprehensive intervention against flies in broiler production houses.     

A physician's guide for the management of hypertriglyceridemia: the etiology of hypertriglyceridemia determines treatment strategy

Hypertriglyceridemia is a common lipid disorder associated to different, highly prevalent metabolic derangements like diabetes mellitus, the metabolic syndrome and obesity. The choice of treatment depends on the underlying pathogenesis and the consequences for atherosclerosis or pancreatitis. A family history, physical examination and analysis of the lipid profile including measurement of apolipoprotein B or non-HDL-C are necessary to establish the underlying primary or secondary cause. Due to physiological diurnal variations of triglycerides (TG), the time of measurement (fasting or postprandial) should be taken into account when evaluating TG values. Increased awareness arises concerning the impact of postprandial hypertriglyceridemia on the development of atherosclerosis. Hypertriglyceridemia is strongly associated to postprandial hyperlipidemia, remnant accumulation, increased small dense LDL concentrations, low HDL-C, increased oxidative stress, endothelial dysfunction, leukocyte activation and insulin resistance. All these factors are strongly linked to the development of atherosclerosis. Treatment should be aimed at reducing the secretion of triglyceride-rich lipoproteins, increasing intravascular lipolysis and reducing the number of circulating remnants. The main intervention is a change of lifestyle with decreased alcohol consumption, increased physical activity, dietary changes and, if applicable, adaptation of used medication. Fibrates, fish oil and nicotinic acid are the first choice of treatment in sporadic and familial hypertriglyceridemia to reduce the risk of pancreatitis, whereas high dose statins, sometimes in combination with fibrates, nicotinic acid, or fish oil capsules, are indicated for familial combined hyperlipidemia. Statins are necessary to reach low LDL-C concentrations in patients with type 2 diabetes mellitus and statin dosage should be increased when hypertriglyceridemia is present to reach secondary treatment targets for apolipoprotein B or non-HDL-C. Finally, family screening is mandatory to detect familial lipid disorders for early intervention in other family members.     

A systematic review and meta-analysis of interventions used to reduce exposure to house dust and their effect on the development and severity of asthma

OBJECTIVES: We assessed whether any household dust reduction intervention has the effect of increasing or decreasing the development or severity of atopic disease. DATA SOURCES: Electronic searches on household intervention and atopic disease were conducted in January 2007 in EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. No date or language restriction was placed on the literature search. DATA EXTRACTION: We included randomized controlled trials comparing asthma outcomes in a household intervention group with either placebo intervention or no intervention. DATA SYNTHESIS: Fourteen studies met the inclusion criteria. Eight recruited antenatally and measured development of atopic disease. Six recruited known atopic individuals and measured disease status change. Meta-analyses on the prevention studies found that the interventions made no difference to the onset of wheeze but made a significant reduction in physician-diagnosed asthma. Meta-analysis of lung function outcomes indicated no improvement due to the interventions but found a reduction in symptom days. Qualitatively, health care was used less in those receiving interventions. However, in one study that compared intervention, placebo, and control arms, the reduction in heath care use was similar in the placebo and intervention arms. CONCLUSIONS: This review suggests that there is not sufficient evidence to suggest implementing hygiene measures in an attempt to improve outcomes in existing atopic disease, but interventions from birth in those at high risk of atopy are useful in preventing diagnosed asthma but not parental-reported wheeze.     

A systematic review and meta-analysis of interventions used to reduce exposure to house dust and their effect on the development and severity of asthma

We assessed whether any household dust reduction intervention has the effect of increasing or decreasing the development or severity of atopic disease. Electronic searches on household intervention and atopic disease were conducted in 2007 in EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing asthma outcomes in a household intervention group with either placebo intervention or no intervention. Meta-analyses on the prevention studies found that the interventions made no difference to the onset of wheeze but made a significant reduction in physician-diagnosed asthma. Meta-analysis of lung function outcomes indicated no improvement due to the interventions but found a reduction in symptom days. Qualitatively, health care was used less in those receiving interventions. However, in one study that compared intervention, placebo, and control arms, the reduction in heath care use was similar in the placebo and intervention arms. This review suggests that there is not sufficient evidence to suggest implementing hygiene measures in an attempt to improve outcomes in existing atopic disease, but interventions from birth in those at high risk of atopy are useful in preventing diagnosed asthma but not parental-reported wheeze.     

Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a serious complication for home parenteral nutrition (HPN) patients. To reduce the incidence of infection in frequently infected HPN patients, prophylactic ethanol lock therapy (ELT) was initiated. METHODS: Nine patients were selected as candidates for ELT because of their history of recurrent CRBSI. Diagnosis of CRBSI was determined by symptoms correlating with positive peripheral and access device blood cultures. Medical-grade ethyl alcohol 25%-70% was instilled into the central venous access device and allowed to dwell for 2-4 hours. The incidence of CRBSI and catheter changes was compared before and after initiation of ELT. RESULTS: Nine patients experienced 81 CRBSIs (8.3 per 1,000 catheter-days) before starting ELT vs 9 infections (2.7 per 1,000 catheter-days: relative risk [RR], 0.325; confidence interval [CI] 95%, 0.17-0.64) after ELT. Catheter changes were also reduced from 69 (7.0 per 1000 days) before ELT to 1 (0.3 per 1,000 days: RR, 0.043; CI 95%, 0.01-0.25) after ELT. No significant adverse effects were noted, although some patients complained of transient dizziness and nausea. CONCLUSIONS: ELT shows promise in reducing the incidence of CRBSI in the frequently infected HPN population. Further studies are warranted.