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Routine gastric residual volume measurement and energy target achievement in the PICU: a comparison study.
Tume, LN, Bickerdike, A, Latten, L, Davies, S, Lefèvre, MH, Nicolas, GW, Valla, FV
European journal of pediatrics. 2017;(12):1637-1644
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Abstract
UNLABELLED Critically ill children frequently fail to achieve adequate energy intake, and some care practices, such as the measurement of gastric residual volume (GRV), may contribute to this problem. We compared outcomes in two similar European Paediatric Intensive Care Units (PICUs): one which routinely measures GRV (PICU-GRV) to one unit that does not (PICU-noGRV). An observational pilot comparison study was undertaken. Eighty-seven children were included in the study, 42 (PICU-GRV) and 45 (PICU-noGRV). There were no significant differences in the percentage of energy targets achieved in the first 4 days of PICU admission although PICU-noGRV showed more consistent delivery of median (and IQR) energy targets and less under and over feeding for PICU-GRV and PICU-noGRV: day 1 37 (14-72) vs 44 (0-100), day 2 97 (53-126) vs 100 (100-100), day 3 84 (45-112) vs 100 (100-100) and day 4 101 (63-124) vs 100 (100-100). The incidence of vomiting was higher in PICU-GRV. No necrotising enterocolitis was confirmed in either unit, and ventilator-acquired pneumonia rates were not significantly different (7.01 vs 12 5.31 per 1000 ventilator days; p = 0.70) between PICU-GRV and PICU-noGRV units. CONCLUSIONS The practice of routine gastric residual measurement did not significantly impair energy targets in the first 4 days of PICU admission. However, not measuring GRV did not increase vomiting, ventilator-acquired pneumonia or necrotising enterocolitis, which is the main reason clinicians cite for measuring GRV. What is known: • The practice of routinely measuring gastric residual volume is widespread in critical care units • This practice is increasingly being questioned in critically ill patients, both as a practice that increases • The likelihood of delivering inadequate enteral nutrition amounts and as a tool to assess feeding tolerance What is new: • Not routinely measuring gastric residual volume did not increase adverse events of ventilator acquired pneumonia, necrotising enterocolitis or vomiting. • In the first 4 days of PICU stay, energy target achievement was not significantly different, but the rates of under and over feeding were higher in the routine GRV measurement unit.
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Incomplete type of intestinal metaplasia has the highest risk to progress to gastric cancer: results of the Spanish follow-up multicenter study.
González, CA, Sanz-Anquela, JM, Companioni, O, Bonet, C, Berdasco, M, López, C, Mendoza, J, Martín-Arranz, MD, Rey, E, Poves, E, et al
Journal of gastroenterology and hepatology. 2016;(5):953-8
Abstract
BACKGROUND AND AIM In high or moderate risk populations, periodic surveillance of patients at risk of progression from gastric precursor lesions (PL) to gastric cancer (GC) is the most effective strategy for reducing the burden of GC. Incomplete type of intestinal metaplasia (IIM) may be considered as the best candidate, but it is still controversial and more research is needed. To further assess the progression of subtypes of IM as predictors of GC occurrence. METHODS A follow-up study was carried-out including 649 patients, diagnosed with PL between 1995-2004 in 9 participating hospitals from Spain, and who repeated the biopsy during 2011-2013. Medical information and habits were collected through a questionnaire. Based on morphology, IM was sub-classified as complete (small intestinal type, CIM) and incomplete (colonic type, IIM). Analyses were done using Cox (HR) models. RESULTS At baseline, 24% of patients had atrophic gastritis, 38% CIM, 34% IIM, and 4% dysplasia. Mean follow-up was 12 years. 24 patients (3.7%) developed a gastric adenocarcinoma during follow-up. The incidence rate of GC was 2.76 and 5.76 per 1,000 person-years for those with CIM and IIM, respectively. The HR of progression to CG was 2.75 (95% CI 1.06-6.26) for those with IIM compared with those with CIM at baseline, after adjusting for sex, age, smoking, family history of GC and use of NSAIDs. CONCLUSIONS IIM is the PL with highest risk to progress to GC. Sub-typing of IM is a valid procedure for the identification of high risk patients that require more intensive surveillance.
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Sevalamer Hydrochloride, Sevelamer Carbonate and Lanthanum Carbonate: In Vitro and In Vivo Effects on Gastric Environment.
Coppolino, G, Lucisano, S, Rivoli, L, Fuiano, G, Villari, A, Villari, I, Leonello, G, Lacquaniti, A, Santoro, D, Buemi, M
Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy. 2015;(5):471-6
Abstract
Hyperphosphatemia is common in patients with chronic renal failure. Phosphate binders are associated with gastric intolerance, representing the main reason of drug discontinuation. The aim of this study was to compare the effects in vitro and in vivo of sevelamer hydrochloride (SH), sevelamer carbonate (SC) and lanthanum carbonate (LC) on gastric microenvironment. We have also evaluated the efficacy and tolerability of these drugs in hemodialysis (HD) patients. In vitro analysis: Dissolution time, ability to uptake phosphorus, changes in pH starting from gastric milieu and the amount of carbon dioxide (CO(2)) produced were the variables analyzed. In vivo analysis: 24-h esophago-gastric pH measurement was evaluated in 24 HD patients treated with phosphate binders and proton pump inhibitor (PPI). In vitro: LC dissolved over a longer time compared with SC (58 ± 2.4 vs. 12 ± 0.6 min; P < 0.001) and SH (58 ± 2.4 vs. 10.3 ± 0.8 min; P < 0.001), determining the most alkaline pH. SC had the highest chelation power, binding 4.00 × 10(-9) mol/L of phosphoric acid. CO2 volume released was increased in LC solution (53.2 ± 7.8) compared to SC (33.9 ± 6.2; P < 0.001) and SH (2.3 ± 1.8; P < 0.001). In vivo: gastric pH increased after administration of phosphate binder. The most alkaline pH was recorded in patients treated with SC. The alkalinization of the gastric environment was not prevented by PPI therapy. 424 episodes of esophageal reflux were registered, 74% of them were alkaline. The LC group was characterized by the highest number of episodes. Sevelamer carbonate had a greater capacity and rapidity to chelate phosphorus, with a mild tolerability, due to its low CO(2) production. Sevelamer HCl was the most tolerated chelator because it did not produce CO(2), while lanthanum carbonate was the least soluble.
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Neonatal stomach volume and physiology suggest feeding at 1-h intervals.
Bergman, NJ
Acta paediatrica (Oslo, Norway : 1992). 2013;(8):773-7
Abstract
UNLABELLED There is insufficient evidence on optimal neonatal feeding intervals, with a wide range of practices. The stomach capacity could determine feeding frequency. A literature search was conducted for studies reporting volumes or dimensions of stomach capacity before or after birth. Six articles were found, suggesting a stomach capacity of 20 mL at birth. CONCLUSION A stomach capacity of 20 mL translates to a feeding interval of approximately 1 h for a term neonate. This corresponds to the gastric emptying time for human milk, as well as the normal neonatal sleep cycle. Larger feeding volumes at longer intervals may therefore be stressful and the cause of spitting up, reflux and hypoglycaemia. Outcomes for low birthweight infants could possibly be improved if stress from overfeeding was avoided while supporting the development of normal gastrointestinal physiology. Cycles between feeding and sleeping at 1-h intervals likely meet the evolutionary expectations of human neonates.
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Laparoscopic gastric plication versus mini-gastric bypass surgery in the treatment of morbid obesity: a randomized clinical trial.
Darabi, S, Talebpour, M, Zeinoddini, A, Heidari, R
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2013;(6):914-9
Abstract
BACKGROUND Laparoscopic gastric plication (LGP) is emerging as a safe and effective bariatric procedure. However, there are no reports on the comparison between the efficacy and complications of LGP and laparoscopic mini-gastric bypass (LMGB), which is still an investigational bariatric procedure. The objective of this study was to compare safety and efficacy of LGP and LMGB in the treatment of morbid obesity in a one-year follow-up study. METHODS Forty patients met the National Institutes of Health criteria and were randomly assigned to receive either LGP (n = 20) or LMGB (n = 20) by a block randomization method. Early and late complications, body mass index (BMI), excess weight loss, and obesity-related co-morbidities were determined at the 1-year follow-up. RESULTS Operative time and mean length of hospitalization were shorter in the LGP group (71.0 minutes versus 125.0 minutes, P<.001, and 1.6 days versus 5.2 days; P<.001, respectively). The mean percentage of excess weight loss (%EWL) at 12 months follow-up was 66.9% in the LMGB group and 60.8% in the LGP group (P = .34). Improvement was observed in all co-morbidities in both groups, with the exception of hyperlipidemia, which remained unresolved in 4 patients. Lower incidence of iron deficiency occurred in the LGP group (P = .035). Rehospitalization and reoperation were not required in any cases. Considering the cost of instruments used in the LMGB procedure and operative time, LGP saved approximately $2,500 per case compared with LMGB. CONCLUSION Both LGP and LMGB are effective weight loss procedures. LGP proved to be a simpler and less costly procedure compared with LMGB with a lower risk of iron deficiency during a 1-year follow-up study.
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Effects of varying combinations of intraduodenal lipid and carbohydrate on antropyloroduodenal motility, hormone release, and appetite in healthy males.
Seimon, RV, Feltrin, KL, Meyer, JH, Brennan, IM, Wishart, JM, Horowitz, M, Feinle-Bisset, C
American journal of physiology. Regulatory, integrative and comparative physiology. 2009;(4):R912-20
Abstract
Intraduodenal infusions of both lipid and glucose modulate antropyloroduodenal motility and stimulate plasma CCK, with lipid being more potent than glucose. Both stimulate glucagon-like peptide-1, but only lipid stimulates peptide YY (PYY), while only glucose raises blood glucose and stimulates insulin. When administered in combination, lipid and carbohydrate may, thus, have additive effects on energy intake. However, elevated blood glucose levels do not suppress energy intake, and the effect of insulin is controversial. We hypothesized that increasing the ratio of maltodextrin, a complex carbohydrate, relative to lipid would be associated with a reduction in effects on antropyloroduodenal pressures, gut hormones, appetite, and energy intake, when compared with lipid alone. Ten healthy males were studied on three occasions in double-blind, randomized order. Antropyloroduodenal pressures, plasma CCK, PYY and insulin, blood glucose, and appetite were measured during 90-min intraduodenal infusions of 1) 3 kcal/min lipid (L3), 2) 2 kcal/min lipid and 1 kcal/min maltodextrin (L2/CHO1), or 3) 1 kcal/min lipid and 2 kcal/min maltodextrin (L1/CHO2). Energy intake at a buffet lunch consumed immediately after the infusion was quantified. Reducing the lipid (thus, increasing the carbohydrate) content of the infusion was associated with reduced stimulation of basal pyloric pressures (r = 0.76, P < 0.01), plasma CCK (r = 0.66, P < 0.01), and PYY (r = 0.98, P < 0.001), and reduced suppression of antral (r = -0.64, P < 0.05) and duodenal (r = -0.69, P < 0.05) pressure waves, desire-to-eat (r = -0.8, P < 0.001), and energy intake (r = 0.74, P < 0.01), with no differences in phasic (isolated) pyloric pressures. In conclusion, in healthy males, intraduodenal lipid is a more potent modulator of gut function, associated with greater suppression of energy intake, when compared with isocaloric combinations of lipid and maltodextrin.
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Comparison of cardiac and gastric responses to vagal stimulation in hypertensive women.
Thor, PJ, Furgała, A, Mazur, M, Pośnik-Urbańska, A, Kolasińska-Kloch, W, Czarnecka, D, Kawecka-Jaszcz, K
Medical science monitor : international medical journal of experimental and clinical research. 2009;(10):CR504-511
Abstract
BACKGROUND The aim was to evaluate the interactions between the effects of vagal stimulation by sham feeding (nonbaroreflex) and deep breathing (baroreflex) on heart rate variability (HRV) and gastric myoelectrical activity (GMA) in pre- and postmenopausal women with essential hypertension. MATERIAL/METHODS One hundred five post- and premenopausal women with hypertension and 60 premenopausal normotensive women were observed. The study protocol consisted of 5 min of resting HRV followed by 5 min of deep breathing (DB), then 6 min of sham feeding (SF) with 30-min electrogastrography (EGG) before and after SF. The fasting plasma level of noradrenalin was measured. RESULTS The HRV parameter values at rest in the hypertensive group were half those in the control group (p<0.05). There were notably higher HRV parameter values in the premenopausal women. Plasma noradrenalin level was higher in the postmenopausal women (p=0.0009). The effect of DB was similar before and after menopause; however, HRV parameters in response to DB were lower in the hypertensive women than in the controls (p<0.05). In the controls there was a marked increase in the main HRV parameters in response to DB. In fasting electrogastrography the lowest normogastria percentage was observed in the postmenopausal women. EGG showed that only SF significantly affected the period dominant power (PDP) in all groups and the bradygastria percentage in the postmenopausal women. CONCLUSIONS This study suggests that the interactions that occur between the effects of non-baroreflex and baroreflex vagal stimulation in hypertensive women may contribute to gastric motility disorders and dyspeptic symptoms.
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Endoscopic and symptomatic assessment of anastomotic strictures following esophagectomy and cervical esophagogastrostomy.
Williams, VA, Watson, TJ, Zhovtis, S, Gellersen, O, Raymond, D, Jones, C, Peters, JH
Surgical endoscopy. 2008;(6):1470-6
Abstract
BACKGROUND Dysphagia following esophagectomy with cervical esophagogastric anastomosis is common and often can be attributed to anastomotic stricture. The prevalence, risk factors, symptomatic and endoscopic severity, and response to dilation of such strictures, however, are poorly defined. METHODS In the present study the population consisted of 42 patients undergoing esophagectomy with gastric pull-up and cervical anastomosis. Any complaint of postoperative dysphagia was investigated with upper endoscopy. Patients undergoing endoscopy were entered into a prospective randomized trial of graduated balloon versus bougie-over-a-guidewire dilation that will be part of a future report. Dysphagia was assigned a standardized severity score, and stricture diameter pre-dilation was classified as minimal (>12 mm), mild (9-12 mm), moderate (5-8 mm), or severe (<5 mm). Outcome measures included the incidence, time to first dilation, symptomatic and endoscopic severity of anastomotic strictures, number of dilations, and influence of co-morbidities and anastomotic technique on stricture occurrence. RESULTS Twenty-seven of 41 (66%) surviving patients underwent endoscopy and dilation. Median time to presentation was 2.4 months (min, 27 days; max, 11 months). Most patients (63%) with stricture complained of dysphagia with every meal. The majority (93%) of strictures were mild to moderate (5-12 mm), and there was no correlation between dysphagia frequency and stricture size. Tolerance of an unrestricted diet decreased with increasing stricture severity. In all, 98 dilation sessions were performed without complication. A higher stricture rate was noted following handsewn anastomoses as compared to combined stapled and handsewn anastomoses (85.7% versus 55.5%; p = 0.044). CONCLUSIONS Most patients with symptomatic anastomotic strictures following esophagectomy with cervical esophagogastrostomy present within the first few months following surgery. Half of such strictures are minimal to mild as endoscopically assessed. Dilation is safe, and most patients experience symptomatic relief after only a few dilation sessions. A combined handsewn and stapled anastomosis may decrease the risk of stricture formation relative to a two-layer handsewn technique.
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Effects of exenatide versus sitagliptin on postprandial glucose, insulin and glucagon secretion, gastric emptying, and caloric intake: a randomized, cross-over study.
DeFronzo, RA, Okerson, T, Viswanathan, P, Guan, X, Holcombe, JH, MacConell, L
Current medical research and opinion. 2008;(10):2943-52
Abstract
BACKGROUND This study evaluated the effects of exenatide, a GLP-1 receptor agonist, and sitagliptin, a DPP-4 inhibitor, on 2-h postprandial glucose (PPG), insulin and glucagon secretion, gastric emptying, and caloric intake in T2D patients. METHODS This double-blind, randomized cross-over, multi-center study was conducted in metformin-treated T2D patients: 54% female; BMI: 33 +/- 5 kg/m(2); HbA(1c): 8.5 +/- 1.2%; 2-h PPG: 245 +/- 65 mg/dL. Patients received exenatide (5 microg BID for 1 week, then 10 microg BID for 1 week) or sitagliptin (100 mg QAM) for 2 weeks. After 2 weeks, patients crossed-over to the alternate therapy. Postprandial glycemic measures were assessed via standard meal test; caloric intake assessed by ad libitum dinner (subset of patients). Gastric emptying was assessed by acetaminophen absorption (Clinicaltrials.gov Registry Number: NCT00477581). RESULTS After 2 weeks of therapy, 2-h PPG was lower with exenatide versus sitagliptin: 133 +/- 6 mg/dL versus 208 +/- 6 mg/dL, p < 0.0001 (evaluable, N = 61). Switching from exenatide to sitagliptin increased 2-h PPG by +73 +/- 11 mg/dL, while switching from sitagliptin to exenatide further reduced 2-h PPG by -76 +/- 10 mg/dL. Postprandial glucose parameters (AUC, C(ave), C(max)) were lower with exenatide than sitagliptin (p < 0.0001). Reduction in fasting glucose was similar with exenatide and sitagliptin (-15 +/- 4 mg/dL vs. -19 +/- 4 mg/dL, p = 0.3234). Compared to sitagliptin, exenatide improved the insulinogenic index of insulin secretion (ratio exenatide to sitagliptin: 1.50 +/- 0.26, p = 0.0239), reduced postprandial glucagon (AUC ratio exenatide to sitagliptin: 0.88 +/- 0.03, p = 0.0011), reduced postprandial triglycerides (AUC ratio exenatide to sitagliptin: 0.90 +/- 0.04, p = 0.0118), and slowed gastric emptying (acetaminophen AUC ratio exenatide to sitagliptin: 0.56 +/- 0.05, p < 0.0001). Exenatide reduced total caloric intake compared to sitagliptin (-134 +/- 97 kcal vs. +130 +/- 97 kcal, p = 0.0227, N = 25). Common adverse events with both treatments were mild to moderate in intensity and gastrointestinal in nature. CONCLUSIONS Although this study was limited by a 2-week duration of exposure, these data demonstrate that, exenatide had: (i) a greater effect than sitagliptin to lower postprandial glucose and (ii) a more potent effect to increase insulin secretion and reduce postprandial glucagon secretion in T2D patients. In contrast to sitagliptin, exenatide slowed gastric emptying and reduced caloric intake. These key findings differentiate the therapeutic actions of the two incretin-based approaches, and may have meaningful clinical implications.
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Effect of a selective chloride channel activator, lubiprostone, on gastrointestinal transit, gastric sensory, and motor functions in healthy volunteers.
Camilleri, M, Bharucha, AE, Ueno, R, Burton, D, Thomforde, GM, Baxter, K, McKinzie, S, Zinsmeister, AR
American journal of physiology. Gastrointestinal and liver physiology. 2006;(5):G942-7
Abstract
Chloride channels modulate gastrointestinal neuromuscular functions in vitro. Lubiprostone, a selective type 2 chloride channel (ClC-2) activator, induces intestinal secretion and has been shown to relieve constipation in clinical trials; however, the effects of lubiprostone on gastric function and whole gut transit in humans are unclear. Our aim was to compare the effects of the selective ClC-2 activator lubiprostone on maximum tolerated volume (MTV) of a meal, postprandial symptoms, gastric volumes, and gastrointestinal and colonic transit in humans. We performed a randomized, parallel-group, double-blind, placebo-controlled study evaluating the effects of lubiprostone (24 microg bid) in 30 healthy volunteers. Validated methods were used: scintigraphic gastrointestinal and colonic transit, SPECT to measure gastric volumes, and the nutrient drink ("satiation") test to measure MTV and postprandial symptoms. Lubiprostone accelerated small bowel and colonic transit, increased fasting gastric volume, and retarded gastric emptying. MTV values were reduced compared with placebo; however, the MTV was within the normal range for healthy adults in 13 of 14 participants, and there was no significant change compared with baseline measurements. Lubiprostone had no significant effect on postprandial gastric volume or aggregate symptoms but did decrease fullness 30 min after the fully satiating meal. Thus the ClC-2 activator lubiprostone accelerates small intestinal and colonic transit, which confers potential in the treatment of constipation.