Assessment of nutritional status and in vivo immune responses in alcoholic liver disease.

Nutritional status and in vivo immune responses were investigated in 30 patients with alcoholic liver disease who were drinking heavily up until emergency hospital admission. Investigations were performed on admission and after 2 wk abstention and adequate hospital diet. No relationship was found between the severity of liver disease revealed histologically and the recent quantity or total duration of alcohol intake, inadequacy of diet, or nutritional status. Skin anergy was more common in those patients with cirrhosis but did not relate to depletion in circulating T lymphocytes, poor nutritional status, or to the direct effect of alcohol toxicity. Acute alcohol toxicity did, however, produce extensive and rapidly reversible metabolic and cellular changes including reduction in serum potassium, magnesium and phosphate and depletion of all circulating lymphocyte subpopulations.

Pulmonary abnormalities in Crohn's disease.

Abnormalities of pulmonary function in Crohn's disease have been described, although the results are conflicting and anecdotal accounts of lung involvement are few. In this study we assessed the prevalence of lung function abnormalities in Crohn's disease, and the relative contributions of age, sex, smoking and past medical history, and Crohn's disease activity to the pulmonary abnormalities found. Twenty-nine patients with Crohn's disease and 29 age-, sex- and smoking-matched volunteer controls underwent detailed respiratory assessment. Airways obstruction due to chronic bronchitis and asthma was present in 13 patients with Crohn's disease, but was not more prevalent than in the control group. FEV1 was similar in both Crohn's disease and control subjects (84.2 +/- 21.2% predicted, mean +/- SD; 93.7 +/- 16.3%, respectively: n.s.). The vital capacity was significantly lower in the Crohn's disease patients than in controls (86.7 +/- 16.6%; 95.9 +/- 12.7%; P less than 0.01), but this may have been influenced by the higher prevalence of past or intercurrent medical illnesses affecting the chest in Crohn's disease patients. No patient had evidence of fibrosing alveolitis or bronchiectasis. The haemoglobin corrected transfer factor was significantly lower in the Crohn's disease patients than in controls (100.4 +/- 17.4%; 113.2 +/- 25.1: P less than 0.05) but the diffusing coefficient was not significantly different. There was a significant correlation (r = 0.44, P less than 0.05) between the residual volume and the Crohn's disease activity index but otherwise no close relationship was observed between Crohn's disease activity, extent or duration and the indices of lung function. These findings suggest that the lungs are relatively unaffected by Crohn's disease.

Mg deficiency in chronic inflammatory bowel disease and requirements during intravenous nutrition.

Assessment of magnesium (Mg) status by serum and 24-hr urine estimations has been used to study a group of 17 patients with severe Crohn's disease, 10 of whom have required intravenous (IV) nutrition. Mg depletion was present in 15 (88%) and severe enough to cause symptoms in two. Urine levels were low in most patients and would appear to be a more sensitive indication of Mg depletion than serum levels alone. Serum Mg levels were significantly lower in the Crohn's group than in a group of hospital controls; 5-10 mmol of IV Mg were required daily to prevent Mg depletion during IV nutrition and some patients required higher intakes. Three patients with particularly severe malabsorption required oral Mg supplements in the long-term. The rationale for using our method of assessing Mg status, and the importance of recognizing and treating chronic Mg deficiency are presented.

Nursing the immobile: a preliminary study.

Permanent loss of mobility has profound physical and mental consequences for both sufferers and carers, and is a major challenge to the National Health Service. A recent study has shown that 42% of beds in departments of Geriatric Medicine are occupied by people with longstanding immobility. These people are highly dependent on nursing staff for their daily activities and quality of life. The assessment of mobility, as a single parameter of dependency, and the measurement of allocated nursing hours are both rapidly and easily performed on geriatric wards. It is felt that a simple correlation of these two variables might highlight areas where more detailed audit is desirable. This study demonstrates that the more immobile patients on a ward, the less the hours allocated to Registered and Learner grade nurses. Some possible reasons for this are suggested and the effects of this deployment on nursing practice and staff recruitment are discussed. It is felt that provision of appropriate nursing care to the most dependent patients in continuing care areas is essential, and that high levels of trained staff are needed to ensure this.

Home enteral tube feeding with a liquid diet in the long term management of inflammatory bowel disease and intestinal failure.

A 35-year-old man, who had spent 10 1/2 out of 18 months in hospital, has required repeated courses of intravenous nutrition (IVN) because of nutritional failure due to severe inflammatory bowel disease. He has been maintained on a nocturnal pump-fed liquid diet supplementing his day-time oral diet for five months, four of which have been at home. The cost of such therapy is less than with an elemental diet and there are other advantages. This regime has been shown to be nutritionally adequate. The need to assess other cheaper liquid diets in patients with intestinal failure is recognised.

Covert inhalation of tablet causing fatal pneumonia.

Inhalation of foreign bodies is usually associated with acute respiratory symptoms. We report a case of an elderly woman who died from pneumonia due to covert tablet inhalation. Clinicians caring for the elderly should consider this as a possible cause for pneumonia which fails to respond to usual therapy.

Effects of dietary gluten elimination in patients with recurrent minor aphthous stomatitis and no detectable gluten enteropathy.

Fifty patients with a history of minor recurrent aphthous stomatitis were entered into a 6-month double-blind controlled trial of a gluten-free diet. After hematologic and biochemical investigations and jejunal biopsy, one half of the group was given a gluten-free diet; the other half served as controls and received a gluten-free diet supplemented by gluten given blind (control diet). Twenty-three patients completed the trial, 11 patients on a gluten-free diet, 12 on the control diet. Four of the 11 on the gluten-free diet and 7 of the 12 on the control diet reported significant benefit in terms of minor recurrent aphthous stomatitis, but there was no statistical difference between the responses. The results fail to support studies that report widespread benefit in aphthae of gluten withdrawal and suggest simply a marked placebo response in the condition.

Gastroduodenal mucosal surface and luminal pH in gastric ulcer.

Gastroduodenal mucosal surface pH was measured in situ by electrode in endoscopically normal and gastric ulcer patients. With the exception of the antrum, mucosal surface pH in the ulcer group (GU) resembled that of the endoscopically normal group. In contrast, the antral mucosal surface pH of the GU group of 7.06 +/- 0.11 (22) was significantly (P less than 0.001) higher than that of 5.46 +/- 0.36 (34) for the endoscopically normal group. This difference was also evident when comparison was restricted to subjects in both groups having a fundal luminal fluid pH of less than 3. When the fundal luminal pH was below pH 3, antral mucosal surface pH was 4.79 +/- 0.41 (24) in endoscopically normal subjects and significantly less (P less than 0.001) than the value of 6.98 +/- 0.18 (12) for gastric ulcer patients. Mucosal surface alkalinity of the GU antrum may be a response to damage but seems inappropriate in view of the likelihood of acid dependent inhibition of gastric acid secretion.

Clinical experience of zinc supplementation during intravenous nutrition in Crohn's disease: value of serum and urine zinc measurements.

Serum zinc concentrations and urine zinc excretion have been studied in 10 patients with severe Crohn's disease before and during 59 patient-weeks of intravenous nutrition. Before serum zinc concentrations (9.9 +/- 1.0 mumol/l: mean +/- SEM) and urine zinc excretion (3-3 +/- 0.6 mumol/24h) were less than controls (p less than 0.01). No patients had clinical signs of zinc deficiency before intravenous nutrition and none developed signs during it. There was no overall change in serum zinc concentrations, despite improvements in body weight, skinfold thickness, and mid-arm circumference in all patients, and increased serum albumin and serum transferrin concentrations during all but two periods of intravenous nutrition. Nor was there any relationship between serum zinc concentrations and zinc uptake (up to 220 mumol/day), serum zinc concentrations remaining significantly lower than control levels. Urine zinc excretion during the first week of intravenous nutrition showed a 1.2 to 53-fold increase (mean 11-fold) over pre-intravenous nutrition levels, and a positive relationship was demonstrated between zinc intake and urine zinc excretion. It is suggested that zinc supplied by the intravenous route is inefficiently transported to the tissues, and that some is excreted in the form of small molecular weight chelates into urine. Recommendations are made for the supply of intravenous zinc, based on monitoring urine zinc excretion in individual patients.

A prospective survey of radiological bone and joint changes in primary biliary cirrhosis.

A prospective survey of radiological bone and joint changes was undertaken in 42 patients with primary biliary cirrhosis (PBC) and 23 patients with alcoholic or cyptogenic cirrhosis who formed a control population. PBC patients were commonly found to have hypertrophic osteoarthropathy (38%), joint erosions (31%) and osteoporosis, these results being significantly different from the control group. Hypertrophic osteoarthropathy most frequently affected the first metacarpal and was rarely associated with finger clubbing or clinical symptoms. Joint erosions were most evident in the hands, often associated with a positive rheumatoid factor but only accompanied by symptomatic arthritis in four cases. Patients with PBC show a high prevalence of symptomless bone and joint changes which may become manifest clinically only as the disease progresses; radiography of the hands is recommended as a screening test for these changes.

Vitamin A deficiency in Crohn's disease.

Fifty two patients with Crohn's disease (31 outpatients and 21 inpatients) were investigated for evidence of vitamin A deficiency. Eleven (21%) had low plasma retinol concentrations (less than 1.2 mumol/l (34.3 micrograms %)). Five of these were outpatients and plasma retinol was only slightly reduced (greater than 1.0 mumol/l (28.6%)). All outpatients weighed 80% or more of ideal, and were considered at low risk of developing vitamin A deficiency. In contrast, of the six inpatients with low plasma retinol concentration, five had a level of less than 1.0 mumol/l (28.6 micrograms %) and weighed less than 80% ideal. Three of these had impaired dark adaptation and a plasma retinol concentration of less than 0.8 mumol/l (less than 22.9 micrograms %). As a group, the inpatients were more protein depleted than the outpatients, with respect to serum albumin (p less than 0.01), transferrin (p less than 0.001), and prealbumin (p less than 0.001) but retinol binding protein levels were not significantly lower. It is suggested that patients with extensive small bowel Crohn's disease, who weigh less than 80% of ideal weight, merit measurement of plasma retinol concentration. Those with plasma retinol less than 0.8 mumol/l (less than 22.9 micrograms %) run a high risk of night blindness. Vitamin supplements should be given and protein depletion corrected.