Osmolality of Modified Enteral Tube Feeds for Adults in Hospitals Across the Western Cape Province

Objectives: The first aim of this study was to determine the incidence of use; reasons for use; and procedures/recipes followed in modifying enteral tube feeds (ETFs) for adults in state and private hospitals across the Western Cape Province (WCP); South Africa (baseline data). The second aim was to determine the osmolality of the modified ETFs used by these hospitals (osmolality data). Design: A descriptive cross-sectional study. Setting and subjects: The study was conducted in January/February 2007. The baseline data was collected by means of a coded questionnaire sent to all state and private hospitals in the WCP (n = 111); excluding all children's hospitals. The osmolality data was obtained by means of freeze-point depression of the modified ETF recipes obtained from the participating hospitals. Results: A total response rate of 94was obtained. Of the participating hospitals (n = 104); 48were state (n = 50) and 52were private hospitals (n = 54). Sixty-two per cent of hospitals (n = 64) made use of ETFs; with 25modifying their feeds (n = 16). Twelve recipes were obtained for the osmolality testing. Eight recipes (66) were significantly lower (p 0.001); two (16) were significantly higher (p 0.001) and two of the recipes did not differ from the standard enteral product. Eight recipes (66) had a significantly higher average osmolality (p 0.001) than that of body fluid. The concentrated ETF recipe (1.43 kcal/ml) had the highest osmolality (707 mOsm/kg/H20). Conclusions: Modular ETFs had lower average osmolality than those of the semi-modular and the standard enteral products; and of body fluid (300 mOsm/kg/H20)

Spontaneous bacterial peritonitis and bacteremia due to Leuconostoc species in a patient with end-stage liver disease: a case report.

This report describes a case of spontaneous bacterial peritonitis in a patient with end stage liver disease in whom Leuconostoc spp. was isolated from blood and ascitic fluid. In common with several previously described patients with cultures positive for Leuconostoc from other body sites, this patient had recently received vancomycin. The antibiotic susceptibilities and mechanism of vancomycin resistance of this Gram-positive bacteria are reviewed.

A prospective study of an algorithm using cardiac troponin I and myoglobin as adjuncts in the diagnosis of acute myocardial infarction and intermediate coronary syndromes in a veteran's hospital.

BACKGROUND: Accurate and cost-effective evaluation of acute chest pain has been problematic for years. The high prevalence of missed myocardial infarctions (MI) has led to conservative triage behavior on the part of physicians, leading to expensive admissions to coronary care units. New algorithms are sorely needed for more rapid and accurate triage of patients with chest pain to appropriate treatment settings. HYPOTHESIS: We sought to test an algorithm for rapid diagnosis of MI and acute coronary syndromes using cardiac troponin I (cTnI) and myoglobin as adjuncts to creatine kinase (CK)-MB. We hypothesized our algorithm would be both sensitive and specific at early time points, and would allow safe stratification of patients not ruling in by conventional CK-MB criteria. METHODS: This was a 6-month prospective study of 505 consecutive patients who presented with chest pain at a university-affiliated veteran's hospital. The percentage of MIs at various time points was identified using combinations of markers. Safety outcomes were assessed by follow-up of patients discharged home. Cost savings analysis was assessed by surveying the physicians as to whether the use of the algorithm affected their disposition of patients. Forty-nine patients ruled in for MI. Using the combination of cTnI, 2-h doubling of myoglobin, and CK-MB, 37 (76%) ruled in at the time of presentation, 43 (88%) at 2 h, and 100% by 6 h. RESULTS: Cardiac troponin I plus a 2-h myoglobin was as accurate as the combination of all three markers and performed better than CK-MB in detecting patients presenting late and as a predictor for complications when CK-MB was normal. Of the 456 patients with normal markers after 6 h, only 140 were sent to the coronary care unit (CCU), and 176 were sent home. A 3-month follow-up showed minimal adverse events. One-half of physicians completing a survey stated the use of markers changed their disposition of patients, leading to an estimated 6-month cost savings of a half-million dollars. CONCLUSIONS: We developed an algorithm using troponin I and myoglobin as adjuncts to usual CK-MB levels that allowed for rapid and accurate assessment of patients with acute MI. It also afforded physicians important input into their decision making as to how best to triage patients presenting with chest pain. Their comfort in sending home certain subgroups of patients who otherwise would have been admitted to the CCU was rewarded with a good short-term prognosis and a large cost savings to the hospital.

Testing a community level research utilization intervention.

Research supports changing practice from heparinized to saline flushes for adults, yet heparin continues to be used in clinical practice. The primary aim of this study was to test the effectiveness of a community level innovation diffusion intervention as a method of stimulating research utilization at three acute care facilities in one community simultaneously. The change advocated was the flushing of intermittent intravenous devices (IID) with saline rather than heparin. Pilot IID units were chosen on which to test the change from the use of heparin to saline flushes. The innovation focused on staff empowerment and was implemented in five phases. The change to saline flushes was successful and has been maintained.

Accuracy of drawing coagulation samples from heparinized arterial lines.

OBJECTIVE: To determine the accuracy of activated partial thromboplastin time and prothrombin time studies when samples are drawn through heparinized arterial lines. METHODS: A total sample of 90 grouped blood samples (from 30 subjects) was used. Patients were all male, with a mean age of 65 and were studied within 24 hours of percutaneous transluminal coronary angioplasty. Each patient had three venous control and arterial line sample sets (a total of 90 blood samples) drawn when routinely ordered for monitoring therapy. For the arterial line sample, a discard volume of the deadspace, deadspace + 2 mL, or deadspace + 4 mL was randomly assigned for each sample. The venous control volumes were the same for all three sample sets. RESULTS: A 2 x 3 repeated measures analysis of variance was used to analyze the results. The independent variables were the source of the sample (venous vs arterial) and the discard volume of arterial blood (deadspace, deadspace + 2 mL, deadspace + 4 mL). The dependent variables were the activated partial thromboplastin time and prothrombin time values. Mean arterial activated partial thromboplastin time values were significantly higher than the corresponding venous values. Mean activated partial thromboplastin time values were not significantly different among the discard volumes of blood drawn. However, there was a significant source by volume interaction. Tukey post-hoc comparisons of venous-arterial activated partial thromboplastin time differences among the three volumes showed significant differences between deadspace volume and deadspace + 2 mL, and deadspace volume and deadspace + 4 mL. There was no significant difference between deadspace + 2 mL and deadspace + 4 mL volumes. CONCLUSION: Results indicated that the minimal amount of discard volume for accurate activated partial thromboplastin time values in this population of percutaneous transluminal coronary angioplasty patients was the catheter deadspace volume plus 2 mL (total 3.6 mL).

Effects of a thromboxane-receptor antagonist, BAY u 3405, on prostaglandin D2- and exercise-induced bronchoconstriction.

In the pathogenesis of exercise-induced bronchoconstriction (EIB), prostaglandin D2 (PGD2) may play a role as a newly generated, mast cell-derived mediator. As the bronchoconstrictor effects of PGD2 are predominantly mediated via stimulation of thromboxane receptors in the lung, we studied a novel, orally effective, thromboxane-receptor antagonist, BAY u 3405, on EIB in 12 male subjects with mild asthma. On 4 study days, we determined, in a randomized, double-blind, placebo-controlled, crossover fashion, the effects of 20 mg of BAY u 3405 administered orally 1 hour before PGD2 and exercise challenges, respectively. Increasing dosages of PGD2 were inhaled to establish dose-response curves that allowed determination of the provocative concentration necessary to decrease FEV1 by at least 20% (PC20) and to increase specific airway resistance (SR(aw)) by 100% (PC100). EIB was measured as a maximal fall/increase in postexertional FEV1/SR(aw) after bicycle exercise and cold-air breathing. Prechallenge lung-function values were similar on all four occasions. BAY u 3405 did not elicit any effect on resting bronchial tone. After placebo, the geometric means (SD) of PC20 and PC100 were 0.0380 (2.6) and 0.0266 (2.4) mg/ml, increasing to 0.554 (5.9) and 0.143 (8.1) mg/ml after BAY u 3405 (p = 0.0002). Mean (SD) maximal postexertional decrease in FEV1 and increase in SR(aw) after placebo was 29.4% (16.4%) and 280% (135%), and after BAY u 3405, 31.4% (18.1%) and 379% (281%) (not significant). No clinically relevant BAY u 3405-related side effects were observed. From these results we conclude that BAY u 3405 is highly effective in attenuating PGD2-induced bronchoconstriction.(ABSTRACT TRUNCATED AT 250 WORDS)

Developmental milestones in abused children, and their improvement with a family-oriented approach to the treatment of child abuse.

Few objective measures of the efficacy of intervention programs in the treatment of child abuse exist. One such measure may be improvement in the developmental delays often seen in abused children. Using the Learning Assessment Profile, we tested 53 abused children, ages 2.5-5 years, just before and after involvement in our Family Development Center Program (FDC). The FDC emphasizes therapy-group-interaction for parents, where alternative ways of expressing anger are explored. Children attend daily preschool classes, and take occasional outside field trips. Of the 53 children tested 42 (79%) showed greater than expected developmental skills gains. Six children demonstrated no improvement in developmental skills, four of whom had severe developmental delays in one or two areas. Fine motor and language skills were significantly delayed for the group as a whole; these areas showed the greatest improvement after FDC. There did not appear to be an overall association between increased improvement in developmental skills and length of time in the FDC program, although certain subgroups of children appeared to improve with time while others appeared to lose ground. A five-year follow-up study of these children is presently underway. We conclude that a program which involves both parent and child, and focuses on their interaction, appears to be effective in dealing with abusive families; monitoring developmental levels in the abused children is one means of assessing their progress in such a program. Further controlled prospective trials are needed in this area.