Use of wireless motility capsule to determine gastric emptying and small intestinal transit times in critically ill trauma patients.

PURPOSE: The purpose of this study is to use a novel wireless motility capsule to compare gastric emptying and small bowel transit times in critically ill trauma patients and healthy volunteers. MATERIALS AND METHODS: We evaluated gastric emptying, small bowel transit time, and total intestinal transit time in 8 critically ill trauma patients. These data were compared with those obtained in 87 healthy volunteers from a separate trial. Data were obtained with a motility capsule that wirelessly transmitted pH, pressure, and temperature to a recorder attached to each subject's abdomen. RESULTS: The gastric emptying time was significantly longer in critically ill patients (median, 13.9; interquartile range [IQR], 6.6-48.3 hours) than in healthy volunteers (median, 3.0; IQR, 2.5-3.9 hours), P < .001. The small bowel transit time in critically ill patients was significantly longer than in healthy volunteers (median, 6.7 hours; IQR, 4.4-8.5 hours vs median, 3.8 hours; IQR, 3.1-4.7 hours), P = .01. Furthermore, the capsules passed after 10 (IQR, 8.5-13) days in the critical care group and 1.2 (IQR, 0.9-1.9) days in healthy volunteers (P < .001). CONCLUSIONS: Both gastric emptying and small bowel transit were delayed in critically ill trauma patients.

Perspective: Paying physicians to be on call: a challenge for academic medicine.

Paying physicians for on-call services is an emerging national trend. It is fueled by the growing demand for specialty services during nighttime, weekend, and holiday hours, coupled with the changing attitude of physicians, many of whom no longer view being on call as an obligation. Academic health centers (AHCs) serve as stewards of the public's health and are the primary educators for most health care workers. AHCs' policies, including their on-call practices, have significant influence on health care trends and the practice of medicine, but AHC leaders have not reached consensus on whether being on call should be a voluntary or paid responsibility. Graduate medical education programs at AHCs, which insist that trainees adhere to work hours restrictions, are teaching tomorrow's physicians that working fewer hours and getting enough sleep will help reduce medical errors. The unintended consequence is an increasing shortage of physicians who are willing to be on call. Faculty at AHCs need to critically evaluate the multiple factors creating on-call shortages, then formulate and implement practical solutions. Simply offering payment as an incentive for on-call services has not guaranteed the availability of specialty care around the clock and has not addressed the on-call burden for physicians.

Hepatotoxic herbs: will injury mechanisms guide treatment strategies?

Harmful and fatal outcomes related to specific herbal therapies are reported with increasing regularity. However, US physicians remain inadequately informed about potential toxicities. The purpose of this focused review is to highlight past and more recently recognized herbal therapies or complementary and alternative medicine (CAM) that are shown to cause hepatotoxicity. Where available, the proposed mechanisms for toxicity are discussed. An aggressive approach for more stringent regulation of CAM is needed, in addition to a systematic and scientific study of causality and underlying toxic mechanisms, to provide reliable information about the safety of CAM and enable practitioners to deliver effective remedies when toxicities occur.

Determining small intestinal transit time and pathomorphology in critically ill patients using video capsule technology.

PURPOSE: Gastrointestinal motility can be impaired by serious illness or medications, compromising enteral feeding in critical care patients. We compared small bowel transit time and morphology in neurosurgical critical care (ICU) patients with those in healthy subjects. METHODS: We evaluated small intestinal transit time, quality of visualization and intestinal morphology in 16 ICU patients (Glasgow Coma Scale score from 6 to 14) and 16 healthy ambulatory patients. Video data were obtained with PillCam SB capsules (Given Imaging Ltd., Yoqneam, Israel). RESULTS: Transit time was 5.1 h (3.9-7.7) (median [IQR]) in ICU and 4.3 (4.1-5.3 h) in ambulatory patients (P = 0.481). Six ICU patients (37%) and two ambulatory patients (12%) had pathological findings (ulcers, petechia, erosions) (P = 0.10). CONCLUSIONS: Median small bowel transit times in critically ill neurosurgical patients were similar to those in ambulatory subjects, although transit times were more variable in the critically ill patients.

Nutritional supplements and alternative medicine.

PURPOSE OF REVIEW: A major health care trend in the last decade has been the increased use of complementary and alternative medicine and nutritional supplements. Indeed, we now have Physician's Desk References for both herbal therapies and dietary supplements. A large amount of out-of-pocket dollars are spent on complementary and alternative medicine each year in the United States, and complementary and alternative medicine users believe strongly in the efficacy of their treatments. RECENT FINDINGS: In the area of inflammatory bowel disease, probiotics appear to be a highly promising form of therapy. In acute pancreatitis, enteral nutrition has been shown to be safe and effective. Peppermint oil is one of the most widely used complementary and alternative medicine therapies for irritable bowel syndrome. Antioxidants are increasingly used in liver disease, especially agents involved in methionine metabolism. Both S-adenosylmethionine and betaine have shown efficacy in animal models of alcoholic liver disease, and "knockout" mice that develop S-adenosylmethionine deficiency also develop steatohepatitis. Thus, there is great interest in these complementary and alternative medicine agents in both alcoholic liver disease and nonalcoholic steatohepatitis. There are also important safety issues related to complementary and alternative medicine. Deaths of well-known athletes have highlighted the risks of ephedra, and some research suggests that complementary and alternative medicine agents are a major cause of fulminant liver failure necessitating liver transplantation. SUMMARY: Thus, physicians must be aware not only of the potential therapeutic benefits of complementary and alternative medicine agents and nutritional supplements, but also their potential risks, including toxicity and drug interactions.