External duodenal fistula following closure of duodenal perforation.

AIM: Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD: Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS: Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS: EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.     

Pharmacokinetics and Safety of a Selegiline Transdermal System Relative to Single-Dose Oral Administration in the Elderly

This open-label, two-phase cross-over study compared the safety and pharmacokinetics of transdermally administered selegiline and orally administered selegiline hydrochloride in elderly men and women (n = 6/gender). Single oral doses of 10 mg selegiline hydrochloride and single 1/2 and 1 selegiline transdermal system (STS) (delivering similar3.4 and 6.3 mg over 24 h) administered topically were safe and well tolerated in all subjects. Plasma concentrations of selegiline (SEL) and its N-desmethylselegiline (DMS), L-amphetamine (AMP), and L-methamphetamine (MET) metabolites were measured using an HPLC/MS/MS method with lower quantitation limits of 10, 50, 200, and 200 pg/mL, respectively. No significant gender-related differences were observed following single 10-mg oral doses of selegiline hydrochloride or single 24-h applications of 1/2 and 1 STS to elderly males and females. The low level of dermal irritation as assessed by erythema and edema rating scales suggests that the STS was similar to Band-Aid (Johnson & Johnson, Skillman, NJ) controls. The transdermal administration of SEL bypasses the first-pass metabolism, that is significant after oral administration (first-pass extraction >90%). Peak plasma levels of 1.19, 23.22, 4.78, and 14.08 ng/mL were observed for SEL, DMS, AMP, and MET after a single 10-mg oral dose to the elderly. By contrast, peak plasma levels of 2.10, 0.85, 1.06, and 2.71 ng/mL were observed for SEL, DMS, AMP, and MET after a single 24-h application of 1 STS. Comparison of dose-corrected areas under the curve (AUCs) (made under the assumption of linear pharmacokinetics) indicate the SEL exposure after transdermal application was more than 50-fold greater than that obtained orally. This increase in systemic SEL exposure at the expense of metabolite formation that is reduced to <70% of that obtained orally for N-DMS, L-AMP, and L-MET is hypothesized to be of therapeutic value in patients with a variety of neurodegenerative and psychiatric disorders.     

Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy

Digestive Diseases and Sciences - Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel...