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Biomedical subjects

Stephen A McClave

Publications and source records attributed to Stephen A McClave.

At least 19 recordsLinked to original sources
PubMed2006

The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments.

PURPOSE: The safety and efficacy of esophageal dilation is enhanced when direct visualization is possible, tactile sensation and feedback from resistance is maintained, and multiple dilations with a single passage of the dilating device is an option. The InScope Optical Dilator (InScope, a Division of Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) is a flexible, transparent bougie fitted over a standard endoscope, with 3 dilating segments allowing sequential dilation under direct visualization. We report our experience with this device in treating benign esophageal strictures. METHODS: Patients with solid food dysphagia due to peptic strictures or Schatzki's ring were studied by using a 27F or 29F endoscope. Based on stricture appearance and estimated luminal diameter, 1 of 3 dilator sizes was chosen: IN0216 (14-, 15-, and 16-mm dilating segments), IN0218 (16-, 17-, and 18-mm dilating segments), or IN0220 (18-, 19-, and 20-mm dilating segments). RESULTS: Twenty-six patients were dilated and included 17 peptic strictures and 9 Schatzki's rings. Before dilation, most patients reported difficulties with solids at every meal. Median improvement 3 weeks after dilation was rated by patients as "substantial relief." Patients rated the dilation experience as largely "not at all unpleasant" immediately after endoscopy and had no recollection at 3 weeks' follow-up. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies, and visualization was rated as high. CONCLUSION: The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization.

Adolescent↗
PubMed2006

The role of endoscopically placed feeding or decompression tubes.

The minimally invasive nature of endoscopically placed gastrostomy tubes makes them a viable consideration in palliative care. Complications related to the procedure appear to correlate with age and underlying comorbidities.However, in many instances, the scientific basis for establishing benefit or harm from tube placement is methodologically inadequate. Decisions must be preceded by a discussion of the value and potential risk of artificial nutrition in a particular setting, respecting the wishes and beliefs of each patient and his or her family. The decision to use PEG placement for any reason should be consistent with legal and ethical principles, reflect patient autonomy over any other consideration (including beneficence), and arise from a clear determination of the goals of care (and whether the PEG placement will truly help meet those goals). Whenever possible, further studies with better design are needed to evaluate whether the use of PEG truly affects quality of life and patient outcome in palliative care. PEG tubes for decompression are placed successfully most of the time. Symptom relief occurs usually within 7 days of the procedure. Overall, the morbidity related to the PEG procedure for decompression is only slightly higher than when the same technique is used for nutritional purposes. The appropriate timing for PEG tube placement for nutritional support and for decompression throughout the course of disease progression may be difficult to determine and yet may be a factor in its overall efficiency. Only minor modifications of the basic technique used for PEG placement for nutritional purposes are required to adapt the technique to a variety of other applications in palliative care.

Decompression, Surgical↗
PubMed2006

Indirect calorimetry: relevance to patient outcome.

Indirect calorimetry provides an important adjunctive monitor for the provision of nutrition support in the critically ill patient. Accuracy in determining caloric requirements may serve to optimize benefit from nutrition therapy and improve patient outcome. A number of strategies in nutrition management in the intensive care setting (eg, dosing of enteral nutrition, monitoring cumulative caloric balance, and deliberate but "permissive" underfeeding) necessitate the determination of a fairly specific goal for caloric provision. Inaccuracy leading to inappropriate under- or overfeeding may generate additional morbidity and adverse clinical consequences for patients already at high risk from hypermetabolic stress response to injury.

Calorimetry, Indirect↗
PubMed2005

Pre-pyloric versus post-pyloric feeding.

Optimal management of the critically ill patient involves the initiation and rapid advancement of early enteral nutrition (EN). Compared to parenteral nutrition or no nutritional support, early enteral feeding favorably impacts patient outcome by reducing infectious morbidity and shortening hospital length of stay. Controversy exists over the true risks and benefits of pre-pyloric versus post-pyloric feeding. Placement of nasogastric tubes is easier than nasojejunal tubes, initiation of EN is more expedient, and intragastric feeds may provide greater physiologic benefits. Post-pyloric feeding, on the other hand, is associated with fewer interruptions once EN has been started, may reach goal calorie provision sooner, and may reduce risk for gastroesophageal reflux and aspiration. Overall differences in outcome between the two methods of feeding, however, are minimal. Thus, the final choice for the practicing clinician on the level of infusion of enteral feeding is based on institutional factors (related to protocols and available expertise) and the degree of risk and potential tolerance of the individual patient.

Critical Care↗
PubMed2005

Do physician attitudes and practices limit use of EUS in the staging and the treatment of esophageal carcinoma?

BACKGROUND: Although EUS provides superior local staging of esophageal carcinoma when compared with other tests, EUS seems to be underused by physicians. We designed this prospective study to determine whether EUS is ordered in the evaluation of esophageal cancer and whether staging information obtained would change management. METHODS: A total of 114 physicians were mailed a questionnaire that surveyed which tests are used in evaluating patients with esophageal cancer, the order in which they are requested, and their estimated cost. Physicians were asked to estimate prognosis and to indicate which therapy would be used for each specific TNM cancer stage. RESULTS: Of 114 physicians, 71 (62.3%) physicians from 4 disciplines responded. Only 47.3% of physicians would use EUS in the patient workup for esophageal cancer. Physicians would only order EUS after first obtaining an endoscopy, then a barium swallow, and then a CT scan ( p < 0.0001). A significantly greater number of internists (78.9%, p = 0.055) would not order EUS, and 31.6% of internists would not use any staging data before referral to another physician for definitive management. Physicians were accurate in their assessment of the prognosis for each cancer stage and the cost of each test. There was no difference in the use of surgery between disciplines for stages O, I, IIA, and IV. However, significantly more surgeons than nonsurgeons would use surgery for stage IIB (100.0% vs. 71.3%, p = 0.019), with a trend toward greater use by surgeons for stage III (64.3% vs. 34.1%, p = 0.11). Except for significantly greater use of chemotherapy by surgeons and oncologists for stage IIA than internists and gastroenterologists (36.6% vs. 3.1%, p = 0.0006), there were no differences between subspecialties with use of chemotherapy for all other stages or use of radiation therapy for any stage. CONCLUSIONS: Clinicians have an adequate understanding of patient survival based on cancer stage and a reasonable appreciation of cost for diagnostic tests regarding esophageal carcinoma. Specific data on cancer staging does impact treatment choices and management decisions. EUS is grossly underused by clinicians for staging esophageal cancer. Although internists may serve as gatekeepers, they fail to order EUS, order EUS only after less accurate tests, or fail to use staging data in management (especially referral) decisions. The ultimate modality of treatment may be more related to the type of physician that the patient is referred to, instead of the specific cancer stage. Education of primary care clinicians may be needed before the full impact of EUS on patient care can be appreciated.

Adenocarcinoma↗
PubMed2005

Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.

BACKGROUND AND AIMS: Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use. METHODS: Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study. Patients were fed Probalance (Nestle USA) to provide 25 kcal/kg per day (to which 10 yellow microscopic beads and 4.5 mL of blue food coloring per 1,500 mL was added). Patients were randomized to one of two groups based on management of RV: cessation of enteral tube feeding for RV >400 mL in study patients or for RV >200 mL in controls. Acute Physiology and Chronic Health Evaluation (APACHE) III, bowel function score, and aspiration risk score were determined. Bedside evaluations were done every 4 hrs for 3 days to measure RV, to detect blue food coloring, to check patient position, and to collect secretions from the trachea and oropharynx. Aspiration/regurgitation events were defined by the detection of yellow color in tracheal/oropharyngeal samples by fluorometry. Analysis was done by analysis of variance, Spearman's correlation, Student's t-test, Tukey's method, and Cochran-Armitage test. RESULTS: Forty patients (mean age, 44.6 yrs; range, 18-88 yrs; 70% male; mean APACHE III score, 40.9 [range, 12-85]) were evaluated (21 on nasogastric, 19 on percutaneous endoscopic gastrostomy feeds) and entered into the study. Based on 1,118 samples (531 oral, 587 tracheal), the mean frequency of regurgitation per patient was 31.3% (range, 0% to 94%), with a mean RV for all regurgitation events of 35.1 mL (range, 0-700 mL). The mean frequency of aspiration per patient was 22.1% (range, 0% to 94%), with a mean RV for all aspiration events of 30.6 mL (range, 0-700 mL). The median RV for both regurgitation and aspiration events was 5 mL. Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably. Aspiration risk and bowel function scores did not correlate with the incidence of aspiration or regurgitation. Blue food coloring was detected on only three of the 1,118 (0.27%) samples. RV was < or =50 mL on 84.1% and >400 mL on 1.4% of bedside evaluations. Sensitivities for detecting aspiration per designated RV were as follows: 400 mL = 1.5%; 300 mL = 2.3%; 200 mL = 3.0%; and 150 mL = 4.5%. Low RV did not assure the absence of events, because the frequency of aspiration was 23.0% when RV was <150 mL. Raising the designated RV for cessation of enteral tube feeding from 200 mL to 400 mL did not increase the risk, because the frequency of aspiration was no different between controls (21.6%) and study patients (22.6%). The frequency of regurgitation was significantly less for patients with percutaneous endoscopic gastrostomy tubes compared with those with nasogastric tubes (20.3% vs. 40.7%, respectively; p = .046). There was no correlation between the incidence of pneumonia and the frequency of regurgitation or aspiration. CONCLUSIONS: Blue food coloring should not be used as a clinical monitor. Converting nasogastric tubes to percutaneous endoscopic gastrostomy tubes may be a successful strategy to reduce the risk of aspiration. No appropriate designated RV level to identify aspiration could be derived as a result of poor sensitivity over a wide range of RV. Study results do not support the conventional use of RV as a marker for the risk of aspiration.

APACHE↗
PubMed2005

When to feed the patient with gastrointestinal bleeding.

Whether to provide artificial enteral nutrition therapy to a patient with evidence of gastrointestinal bleeding (GIB) creates a difficult clinical dilemma. Concern that enteral feeding may contribute to the morbidity associated with GIB leads to delays in initiating enteral therapy or to cessation of feeding in the patient in whom artificial nutrition support has already been started. Surprisingly, evidence of GIB is not an automatic contraindication to further enteral feeding. Depending on the etiology of the GIB, enteral nutrition may protect the gut mucosa and reduce further bleeding in some patients, actually increase risk for rebleeding in other patients, or serve as a moot point with no relation to further bleeding or morbidity in still other patients. In many cases, an endoscopic evaluation is needed to distinguish the differential etiology of the GIB. The nutrition support specialist needs a full understanding of the physiology behind the varying diagnoses for GIB to know whether feedings can be initiated or continued or whether enteral feedings need to be withheld for 48-72 hours until risk for rebleeding and further morbidity is minimized.

Acute Disease↗
PubMed2005

Simplify the technique of nasoenteric feeding tube placement with a modified suture tie.

Endoscopic placement of nasoenteric feeding tubes is a common technique used in clinical practice. However, use of the endoscopic "drag and pull" method to pull the tube into position by grasping the feeding tube with a biopsy forceps requires considerable skill. In this paper, we describe a modified suture, which markedly diminishes the technical difficulty for nasoenteric feeding tube placement. Patients admitted to the intensive care unit, with evidence of impaired gastric emptying, referred for placement of a nasoenteric tube, were included in this study. A modification of the feeding tube was made by securing two strands of nylon suture to the tip of a 12-Fr feeding tube. Three knots were made along the sutures on both sides. The feeding tube was introduced through the nose and passed into the stomach. Then, placement of the nasoenteric tube was attempted by an endoscopic "drag and pull" method. Eighty-six patients (49% male, mean age of 60 years) underwent 94 procedures for attempted nasoenteric feeding tube placement. Feeding tubes were placed successfully in 91 of 94 (97%) procedures in these patients. The procedures required an average time of range 5 to 14 minutes, and no major complications were incurred. These results indicate that a modified suture tied to the tip of a nasoenteric feeding tube reduces the technical difficulty of the procedure and facilitates rapid successful placement into the small bowel.

Adult↗
PubMed2004

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.

Journal Article↗
PubMed2004

Enteral nutrition in acute pancreatitis: a survey of practices in canadian intensive care units.

INTRODUCTION: Enteral nutrition (EN) is becoming the standard of care for the artificial nutrition support of the patient with severe acute pancreatitis. This study was designed to describe nutrition support practices for acute pancreatitis in Canadian intensive care units (ICUs) and to identify any barriers to the provision of EN in this patient population. METHODS: After an initial letter of invitation, a survey was sent to all Canadian ICUs with a census of > or = 8 beds. At each center, the critical care dietitian was asked 13 questions about usual practice of providing nutrition support to critically ill patients with acute pancreatitis. RESULTS: Out of 62 ICUs successfully contacted through the initial letter that met entry criteria, responses were obtained from 54 (87%). EN was provided to patients with pancreatitis routinely in 13% (7/54) of units, occasionally in 72% (39/54), and never in 15% (8/54) of the ICUs. Technical difficulty obtaining small bowel access, reported by 38 units (72%), and lack of physician support for EN, as noted in 25 units (47%), were identified as the most common barriers to EN in this population. Enteral access was most commonly obtained via the nasojejunal route. The time frame from ICU admission to initiation of EN (when provided) differed widely between centers, varying from up to 24 hours to 48 hours in 22 units (48% of 46 ICUs), 3 to 5 days in 19 units (41%), and >5 days in 5 units (11%). Supplemental parenteral nutrition (PN) was commonly added to EN, routinely at 8 centers (18% of 45 ICUs) and only occasionally in another 20 units (44%). The duration of supplemental PN when used in conjunction with EN was <7 days in 83% (24/29) of the ICUs. When EN was not initiated, PN was used in all but one ICU. CONCLUSION: Although EN is being commonly provided to patients with acute pancreatitis, PN use remains prominent in many ICUs across Canada. Technical difficulty obtaining small bowel access and lack of physician support seem to be the most common barriers impeding use of EN.

Journal Article↗
PubMed2004

Enhancing interpretation of gastric residual volume by refractometry.

The traditional practice of gastric residual volumes (GRVs) is flawed in its design and conception, is poorly standardized in its technique, is an inaccurate measure of gastric emptying, and serves as an insensitive marker for regurgitation and aspiration. The refractive index of a solution (like an enteral formula) is a physical property of that solution, which is remarkably constant and reproducible under varying conditions of concentration, pH, and temperature. Refractometry may be performed quickly and easily at the bedside, requires only a small representative sample of aspirated solution, and provides valuable measurements that can be used to calculate both the true total volume of contents and the specific volume of formula remaining in the stomach. Refractometry complements the use of GRVs as a monitor for patients receiving enteral feeding and should improve the accuracy with which patients at risk for aspiration may be identified.

Journal Article↗
PubMed2003

Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel?

Although the enteral route of enteral feeding is the preferred method of nutrition support for critically ill patients, this important therapeutic strategy is not without risk. In human subjects, the digestion and absorption of nutrients induce typical hemodynamic changes, consisting of an increase in mesenteric blood flow at the expense of reduced systemic blood pressure. On rare occasion when providing aggressive enteral nutrition to critically ill patients, common symptoms of gastrointestinal intolerance may progress to a syndrome of abdominal distention, hypotension, and shock, with the development of small bowel ischemia or necrosis. Although the incidence of small bowel ischemia secondary to enteral feeding is low, the overall clinical outcome is still poor and carries a high mortality rate. Enteral feeding is well tolerated and is probably beneficial in most critically ill patients before and after a period of hypotension. Although enteral nutrition may be used with caution during the period of hypotension, evidence of poor gastrointestinal function (increased nasogastric tube output, unexplained abdominal pain, and abdominal distention), or development of dilated loops of bowel or intramural gas (pneumatosis intestinalis) on radiographic studies should be interpreted as potential indicators of gut ischemia. With progress in our understanding of the pathophysiology, diagnosis, and prevention of ischemic injury to the intestinal mucosa, the strategy of aggressive enteral feeding for critically ill patients may result in a reduction in this major complication and enhanced functional recovery from severe illness.

Journal Article↗
PubMed2003

Gut immunology and the differential response to feeding and starvation.

Animal and human research has established the beneficial effects of enteral nutrition on the gut. Both the innate and acquired immune systems are bolstered by enteral alimentation. Emerging clinical concepts tie these beneficial effects to a significant influence on the host immune response to stressors during critical illness. In this article, we examine how enteral nutrition impacts gastrointestinal immunity and demonstrate how these changes may affect the body's systemic immune response to nongastrointestinal challenges. This modulatory effect occurs because of changes in the pattern of cytokine secretion and alterations in lymphocyte and neutrophil recruitment. Imbalances in these regulatory mechanisms may be the engine driving hyperresponsiveness to subsequent challenges in the critically ill patient.

Journal Article↗