Comparison of a self-inflating bulb syringe and a colorimetric CO2 indicator with capnography and radiography to detect the misdirection of naso/orogastric tubes into the airway of critically ill adult patients.

OBJECTIVE: The objective of this study was to develop a mechanism of discovering misdirection into the airway of naso/orogastric (NG) tubes before they reach their full depth of placement in adults. METHODS: A prospective, observational study was performed in humans, evaluating both the self-inflating bulb syringe (SIBS) and a colorimetric CO2 detector. A prospective convenience sample of 257 NG tube placements was studied in 199 patients in medical ICUs of a tertiary care medical center. Findings were compared to a "standard" (ie, end tidal CO2 results of a capnograph and the results of a chest radiograph performed at the completion of the tube placement). RESULTS: On the first tube placement attempt in any patient, the SIBS had a sensitivity of 91.5% and a specificity of 87.0% in detecting nonesophageal placement, while the colorimetric device exhibited 99.4% sensitivity and 91.3% specificity. On subsequent insertions, the SIBS showed 95.7% sensitivity and 100% specificity, while the colorimetric device exhibited 97.8% sensitivity and 100% specificity. The colorimetric device was eight times more expensive than the SIBS. CONCLUSIONS: The SIBS and the colorimetric CO2 detector are very good at detecting NG tube malpositioning into the airway, although the colorimetric device is slightly more sensitive and specific. Neither method adds substantial time or difficulty to the insertion process. The colorimetric device is substantially more expensive. The decision as to which method to use may be based on local institutional factors, such as expense.

Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series.

BACKGROUND: The utility and safety of endoscopic biliary orifice balloon dilation (EBD) for bile duct stone removal (with use of large-diameter balloons) after biliary endoscopic sphincterotomy (BES) is currently not well established. OBJECTIVE: Our purpose was to evaluate the efficacy and complications of BES followed by > or = 12 mm diameter EBD for bile duct stone removal. DESIGN: Retrospective, multicenter series. SETTING: Five ERCP referral centers in the United States. PATIENTS AND INTERVENTIONS: Patients who underwent attempted removal of bile duct stones by BES followed by EBD with > or = 12 mm diameter dilating balloons were identified by searching the prospectively recorded endoscopic databases from 1999 to 2007. Clinical parameters, endoscopic data, and outcomes were collected and analyzed. RESULTS: One hundred three patients, mean age 70 +/- 17 years (range 23-98 years), with 56 (54%) women, underwent 107 procedures. Eleven patients (11%) had a prior history of acute pancreatitis. Pancreatogram was performed in 15 (14%) patients. Median stone size and median balloon diameter used was 13 mm. Complete stone removal in the first session of EBD was accomplished in 102 (95%) procedures, and mechanical lithotripsy was required in 29 (27%). Six patients (5.4%) had documented procedure-related complications including one patient with severe bleeding and one with severe cystic duct perforation. No acute pancreatitis occurred. CONCLUSION: EBD with a large-diameter balloon in conjunction with BES for bile duct stone removal is effective and relatively safe. This technique appears to be a reasonable alternative option when standard BES and basket or balloon sweep are inadequate to remove bile duct stones.

The prevalence of coronary artery calcium among diabetic individuals without known coronary artery disease.

OBJECTIVES: We sought to examine the age and gender distribution of coronary artery calcium (CAC) by diabetes status in a large cohort of asymptomatic individuals. BACKGROUND: Among individuals with diabetes, coronary artery disease (CAD) is a major cause of morbidity and mortality. Electron-beam tomography (EBT) quantifies CAC, a marker for atherosclerosis. METHODS: Screening for CAC by EBT was performed in 30,904 asymptomatic individuals stratified by their self-reported diabetes status, gender, and age. The distribution of CAC across the strata and the association between diabetes and CAC were examined. RESULTS: Compared with nondiabetic individuals (n = 29,829), those with diabetes (n = 1,075) had higher median CAC scores across all but two age groups (women 40 to 44 years old and men and women > or =70 years old). Overall, the likelihood of having a CAC score in the highest age/gender quartile was 70% greater for diabetic individuals than for their nondiabetic counterparts. CONCLUSIONS: Younger diabetic individuals appear to have calcified plaque burden comparable to that of older individuals without diabetes. These findings call for future research to determine if EBT-CAC screening has an incremental value over the current CAD risk assessment of individuals with diabetes.