Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study.

Postpylorus delivery of enteral feeding is perceived by many experts to be safer than intragastric delivery. To test this assumption, patients with similar Glasgow Coma Scores were given identical enteral formulas continuously via a 10-French nasoenteric tube, placed into the stomach or beyond the second portion of the duodenum. Observations were made for attainment of desired nutrition, bowel changes, and clinical signs of aspiration. Radiographs of the chest and abdomen were obtained every 3 days. If a tube migrated out of a chosen location, it was replaced. Thirty-three patients were studied. Seventeen patients were fed into the stomach and 16 patients were fed postpylorus. The mean duration of enteral feeding was 11.8 days for the gastric group and 10.9 days for the postpylorus group (p = NS). The time to deliver the desired kilocalories was 3.33 and 2.77 days (p = NS) for gastric and postpylorus-fed patients. Tubes displaced similarly in each group, gastric 0.647, postpylorus 0.750 per duration of feeding (p = NS). Chest radiographs met the criteria for aspiration pneumonia in 31.3% of gastric and 40% of postpylorus-fed patients (p = NS). Together, these data indicate that complications from enterally fed patients are equally common whether the distal port of the feeding tube is in the stomach or beyond the second portion of the duodenum.     

Evaluation of monoclonal anti-D reagents using D variant cells

Monoclonal anti-D antibodies submitted to the Third Monoclonal International Workshop were evaluated against a number of D variant cells using standard serological techniques. The monoclonal antibodies were able to discriminate between the cells of Categories Va, VI and DFR but not Category III cells. Cells within each category did not give any aberrant results. The Rh:33 cells behaved as normal Rh(D) positive cells.     

Evaluation of maternal plasma creatine kinase activity as a marker of abnormal early pregnancy

We have tested the value of maternal plasma creatine kinase activity for diagnosing ectopic pregnancies obtained after in-vitro fertilization and embryo transfer. Plasma creatine kinase was assayed in 57 patients: 20 normal, 23 miscarriages and 14 ectopic pregnancies, for a total of 240 samples. All values were in the lower part of the normal range except only one in a miscarrying patient. A statistically significant difference was observed for a cut-off value of 45 IU/l between normal and ectopic pregnancies. However, for this cut-off point, the measurement of plasma creatine kinase activity had a sensitivity of 0.50 and a specificity of 0.76 for the diagnosis of ectopic pregnancy. The positive predictive value was 0.69. Creatine kinase activity measurements are thus of no practical value in this particular population, in which an early and specific marker of ectopic implantation would be of paramount interest. The association of human chorionic gonadotrophin (HCG) determinations and ultrasound scanning of the pelvis still remain the best paraclinical support for an early diagnosis of ectopic implantation.      

The applicability and utility of the MMPI-based offender classification system in a correctional mental health unit

This study investigated the applicability and utility of Megargee and Bohn's MMPI-based offender classification system in correctional mental health units (MHUs). Previous studies found that 11 MHU samples (n = 1723) had substantially more offenders classified in the more pathological MMPI types than did 21 samples (n = 5881) drawn from general male populations in US prisons. In this study of 63 severely disturbed felons, 43% belonged to the most pathological type (‘group How’). Comparing MHU patients with general offenders from the same IvfIvIPI types on staff ratings and case history variables, we found that the MHU patients were significantly poorer in adjustment. Within the MHU sample, there was no difference in case history variables or adjustment ratings between those in the most and least severe MMPI types. These findings differed from those of studies using less severely disturbed, more heterogeneous, MHU populations. It was concluded that, in settings in which the entire population is flagrantly disturbed, the MMPI-based system is more useful in screening potential admissions than it is in making meaningful distinctions among those already admitted.     

Work at sea: a study of sleep,and of circadian rhythms in physiological and psychological functions,in watchkeepers on merchant vessels

Summary Daily diary records of sleep and activity, and 4-h measurements of body temperature, performance and subjective alertness were collected on board ship from 15 watchkeepers on the 4-on/8-off system, and from 28 dayworkers, on both westward and eastward transatlantic voyages. The data from a balanced sample of the subjects were analysed over selected 8-d periods of the voyages where four or five time zones were crossed. During these periods the average amount of daily sleep obtained by dayworkers on the eastward voyage was more than 1 h less than that on the westward voyage, and its quality was rated lower. Watchkeepers' main sleep was also shorter when travelling eastward, but this reduction was partially compensated for by a slightly longer secondary sleep. With the exception of subjective alertness on the eastward voyage, the basic phase of the circadian rhythms in the measured variables adjusted appropriately to the clock changes associated with the time zone crossings. The normal shape of the average daily curves was, however, altered differentially in the two directions of travel; as a result, morning levels of all variables were lower on the eastward voyage than on the westward, but evening levels were higher. These distortions of rhythm waveforms, which probably arose from a combination of endogenous and exogenous factors, add another dimension to the basic problem caused by the effects of circadian rhythms on operational efficiency in the shipboard situation. This problem can only be solved by the development of alternative watchkeeping systems which take full account of these rhythms.Partly supported by a grant from the West German Ministry for Technology and Research, Project Schiff der Zukunft, Part ET 83b     

Work at sea: a study of sleep,and of circadian rhythms in physiological and psychological functions,in watchkeepers on merchant vessels

Summary Sleep length and sleep quality scores were collected on board ships over periods of up to two weeks from 38 watchkeepers working a 4-on/8-off routine and 29 dayworkers. All watchkeepers exhibited fragmented sleeping patterns, which indicated a lack of adaptation of the sleep/wakefulness cycle to the hours of work. There were only slight differences in total sleep length between watchkeepers and dayworkers, however, both groups did not obtain an adequate amount of sleep. Within the watchkeeping crews the 3rd Officers had by far the shortest sleep length. Concerning sleep quality, daytime sleep was generally given the lowest ratings, whereas sleep starting before midnight was on average evaluated as the best, both by watchkeepers and dayworkers. Watchkeeping personnel do not normally have any days off during a voyage so that missed sleep might even amount to a sleep deficit. A solution for this problem could perhaps be a new, stabilized system that allows a single uninterrupted sleep, which is required for full recuperation, to be taken each day.Dedicated to Professor J. Aschoff on the occasion of his 75th birthdayPartly supported by a grant from the Ministry for Technology and Research, Federal Republic of Germany, Project Schiff der Zukunft, Part ET83b     

ALFENTANIL PLASMA CONCENTRATION v. EFFECT RELATIONSHIPS IN CARDIAC SURGICAL PATIENTS

Effects of alfentanil, preceded by lorazepam, on suppressionof haemodynamic and somatic responses to noxious stimuli wasstudied in patients undergoing CABG. Plasma concentration ofalfentanil, somatic and haemodynamic responses were measuredat loss of consciousness, tracheal intubation, sternotomy andduring multiple applications of electrocoagulation. Additionalalfentanil was administered i.v. to control unwanted responses.Study 1 (six patients): lorazepam 0.08 mg kg^–1 by mouth1–2 h before operation, alfentanil priming infusion (60µg kg^–1 min^–1 for 10 min) followed by maintenanceinfusion (4.5 µg kg^–1 min^–1). With mean plasmaalfentanil 1178 (SEM 54) ng ml^–1, two patients requiredsupplementary alfentanil to suppress somatic motor responses;one patient required nitroglycerin to control an increase inarterial pressure which was unresponsive to additional alfentanilfollowing sternotomy. Study 2 (13 patients): lorazepam 0.04mg kg^–1 by mouth as premedication; one of three maintenanceinfusion rates of alfentanil: 5.4 (n=4), 6.6 (n=5), or 7.8 (n=4)µg kg^–1 min^–1, each preceded by a proportionalpriming infusion. With plasma alfentanil 2181 (62)ng ml^–1,somatic motor responses requiring additional alfentanil occurredin nine patients; haemodynamic responses in four of seven patientstested could not be controlled by alfentanil. The highest plasmaconcentration of alfentanil to prevent response to a stimulusother than tracheal intubation was different between the twostudies (P<0.05). We conclude that alfentanil alone is insufficientto suppress haemodynamic and somatic motor responses to noxiousstimulation during CABG and that the role of premedication issignificant. *Department of Anesthesia, Bowman-Gray School of Medicine Winston-Salem,NC 27103, U.S.A. 2114 de Mayo Road, Del Mar, Ca. 92014, U.S.A.