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T N Jones

Publications and source records attributed to T N Jones.

14 recordsLinked to original sources
PubMed1996

Breast and cervical cancer screening among low-income women: impact of a simple centralized HMO intervention.

In 1994, it was estimated that about 44,500 American women would die from breast cancer and 7000 women from cervical cancer. While early detection methods (screening mammography, breast examinations, and pap smears) have proven to be effective means of decreasing these cancers, they are underused by all groups. In particular, low-income women use them least, resulting in their lower survival and higher mortality rates than the rest of the population. This article quantifies the effect of a simple intervention undertaken by a health maintenance organization (HMO) serving the indigent to improve breast and cervical cancer screening rates. The HMO mailed personal letters and newsletter articles to women members > or = 40 years about the need for cancer prevention. Articles also were printed in the monthly HMO newsletters to providers about the benefits of using these early detection methods. A review of provider claims from 574 women showed that baseline utilization rates for screening mammograms and pap smears before the intervention in year 1 (1990) were 14% and 16.4%, respectively. After the intervention, in years 2 and 3, mammograms had increased to 41% and pap smears to 38% for both years, indicating a levelling off effect of the intervention by year 3. These data show that while a significant improvement in screening behaviors was achieved, the intervention impact was limited to only about one third of the sample on the long term. Further, data do not indicate whether behavioral change was initiated as the member or provider level. More research is needed to increase overall screening behavior among the indigent and their physicians. The results reported here provide a baseline against which more intensive interventions can be measured in this setting.

Adult↗
PubMed1991

Selective uptake of glutamine in the gastrointestinal tract: confirmation in a human study.

Recent animal data suggest that the gut plays a far more important metabolic role than previously thought. During critical illness, disruption in bowel barrier function may result in a chronic hypermetabolic state and contribute to multiorgan failure. Animal studies have demonstrated that enterocytes of the gastrointestinal tract use glutamine as a respiratory fuel and during critical illness the consumption of glutamine by the gut significantly increases. The selective uptake of glutamine by the gut, to date, has not been confirmed in humans. Seven patients who sustained multisystem trauma necessitating laparotomy underwent portal venous catheterization. This was done by carefully reopening the obliterated umbilical vein and facilitating access to the left branch of the portal vein using a standard central venous catheter. Portal venous and systemic blood samples were recorded for 5 days after operation. Amino acid levels in both circulations were recorded at 48 h and 5 days. Using Student's t test for related samples, the differences between individual amino acids in portal and systemic circulations were compared. At 48 h, mean(s.d.) portal venous glutamine was 85(5) per cent of the systemic levels (253(80) compared with 296(90) mumol/ml, P less than 0.002). At 5 days, portal glutamine was 87(3) per cent of the systemic levels (255(69) compared with 292(83) mumol/ml, P less than 0.003). Levels of citrulline, a breakdown product of glutamine metabolism, were elevated in the portal venous circulation at 48 h (20(4) compared with 16(3) mumol/ml, P less than 0.005) and at 5 days (21(5) compared with 14(3) mumol/ml, P less than 0.002). No significant differences between any of the other amino acids analysed were identified. This study confirms, for the first time in humans, that selective uptake of glutamine occurs in the gut. In stressed states, glutamine deficiency is associated with gut mucosal atrophy. This has significant implications as glutamine is not provided in most commercially available parenteral and enteral nutrition formulations.

Adolescent↗
PubMed1989

Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal trauma--a critical analysis.

Meeting the increased metabolic demands in the critically injured is a continuing challenge. Benefits of early enteral feeding after abdominal trauma have been previously reported, but the frequency of patient intolerance due to GI complaints remains unclear. One hundred twenty-three patients undergoing emergent laparotomy for major abdominal trauma with an abdominal trauma index greater than or equal to 15 were prospectively randomized to either a control group (n = 52, no enteral nutrition during the first 5 days) or an enteral-fed group (n = 71). The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy and an elemental diet begun 12 h postoperatively, advanced in volume and concentration at 8-h intervals to 100-125 ml/h of full-strength diet. Symptoms of GI complaints (nausea, vomiting, cramping, distention, and diarrhea) were monitored daily and graded as minimal, moderate, or significant. Fifty percent of the control group had one or more GI complaints during the study period; six (12%) developed moderate discomfort. In the enteral group, 59 (83%) patients reported some GI discomfort; 11 had significant complaints (two nausea, seven cramping, six distention, two diarrhea). Nine (13%) of the enteral-fed patients ultimately required total parenteral nutrition supplementation due to GI complaints. The remaining 62 (87%) enteral patients were maintained on the elemental diet for a mean of 7 days (range 5 to 20). By postoperative day 5, patients received an average of 35 kcal/kg and 14.5 g N/day; 66% (41/62) were in positive N balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1989

TEN versus TPN following major abdominal trauma--reduced septic morbidity.

Recent animal models suggest that enteral feeding (TEN) compared to parenteral nutrition (TPN) improves resistance to infection. This prospective clinical trial examined the impact of early TEN vs. TPN in the critically injured. Seventy-five patients with an abdominal trauma index (ATI) greater than 15 and less than 40 were randomized at initial laparotomy to receive either TEN (Vivonex TEN) or TPN (Freamine HBC 6.9% and Trophamine 6%); both regimens contained 2.5% fat, 33% branched chain amino acids, and had a calorie to nitrogen ratio of 150:1. TEN was delivered via a needle catheter jejunostomy. Nutritional support was initiated within 12 hours postoperatively in both groups, and infused at a rate sufficient to render the patients in positive nitrogen balance. The study groups (TEN = 29 vs TPN = 30) were comparable in age, injury severity and initial metabolic stress. Jejunal feeding was tolerated unconditionally in 25 (86%) of the TEN group. Nitrogen balance remained equivalent throughout the study period, at day 5 TEN = -0.3 +/- 1.0 vs. TPN 0.1 +/- 0.8 gm/day. Traditional nutritional protein markers (albumin, transferrin, and retinol binding protein) were restored better in the TEN group. Infections developed in 5 (17%) of the TEN patients compared to 11 (37%) of the TPN group. The incidence of major septic morbidity was 3% (1 = abdominal abscess) in the TEN group contrasted to 20% (2 = abdominal abscess, 6 = pneumonia) with TPN. This clinical study demonstrates that TEN is well tolerated in the severely injured, and that early feeding via the gut reduces septic complications in the stressed patient.

Abdominal Injuries↗
PubMed1988

Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization.

Reprioritization of hepatic protein synthesis, a process involving accelerated production of acute-phase proteins at the expense of constitutive proteins, accompanies major trauma. The impact of isocaloric, isonitrogenous total enteral nutrition (TEN) versus total parenteral nutrition (TPN) on hepatic reprioritization was investigated in a prospective, randomized trial. Of the 59 patients with an abdominal trauma index (ATI) greater than 15 but not more than 40, 45 evaluable patients were followed. Results from 36 (18 TEN, 18 TPN) evaluable patients revealed that mean serum levels of acute-phase proteins increased, whereas mean serum levels increased to a greater extent in the TPN group. The maximal increase from baseline for the acute-phase response in both groups occurred at postinjury day 5 and was significantly higher for alpha 1-antitrypsin (alpha 1AT, p = 0.03) and orosomucoid (p = 0.02) in the TPN group. Nonacute-phase proteins reached a nadir at day 10 in the TPN group and increased in the TEN group; significant differences between TEN and TPN groups appeared for albumin (p = 0.004) and retinol-binding protein (RBP, p = 0.03); alpha 2-macroglobulin (alpha 2M) approached significance at day 10 (p = 0.07). When change from baseline values was compared, day 10 increases in alpha 2M were significantly higher (p = 0.04) in the TEN group. These data suggest that postinjury TEN attenuates reprioritization of hepatic protein synthesis in patients sustaining major trauma.

Abdominal Injuries↗
PubMed1986

Benefits of immediate jejunostomy feeding after major abdominal trauma--a prospective, randomized study.

Benefits of immediate postinjury nutritional support remain ill defined. Seventy-five consecutive patients undergoing emergent celiotomy with an abdominal trauma index (A.T.I.) greater than 15 were randomized prospectively to a control group (no supplemental nutrition during first 5 days) or enteral-fed group. The enteral patients had a needle catheter jejunostomy (N.C.J.) placed at laparotomy with the constant infusion of an elemental diet (Vivonex HN) begun at 18 hours and advanced to 3,000 ml/day (3,000 kcal, 20 gm N2) within 72 hours. Control and enteral-fed groups were comparable with respect to demographic features, trauma mechanism, shock, colon injury, splenectomy, A.T.I., and initial nutritional assessment. Twenty (63%) of the enteral patients were maintained on the elemental diet greater than 5 days; four (12%) needed total parenteral nutrition (T.P.N.). Nine (29%) of the control patients required T.P.N. Nitrogen balance was markedly improved (p less than 0.001) in the enteral-fed group. Although visceral protein markers and overall complication rate were not significantly different, septic morbidity was greater (p less than 0.025) in the control group (abdominal infection in seven and pneumonia in two) compared to the enteral-fed patients (abdominal abscess in three). Analysis of patients with A.T.I. 15-40 disclosed sepsis in seven (26%) of the control versus one (4%) of the enteral-fed group (p less than 0.01). Our clinical experience demonstrates the feasibility of immediate postoperative enteral feeding via N.C.J. after major abdominal trauma, and suggests this early nutrition reduces septic complications in critically injured patients.

Abdominal Injuries↗
PubMed1985

Elevated pulmonary vascular resistance in patients dying from multiple organ failure.

Twenty-one patients with multiple organ failure were studied with hemodynamic monitoring. The five survivors were compared with the 16 nonsurvivors. Significant differences were found in the cardiac index (CI), the left ventricular stroke work index (LVSWI), and the pulmonary vascular resistance index (PVRI). The CI was higher in survivors (4.38 +/- 1.71) than in nonsurvivors (3.43 +/- 1.49). The LVSWI was also higher (43.0 +/- 16.8, 28.7 +/- 12.8) than in nonsurvivors (47.4 +/- 2.91). The PVRI was lower in survivors (168 +/- 122) than in nonsurvivors (474 +/- 291). It is postulated that the elevated PVRI in MOF is related to the adult respiratory distress syndrome.

Adult↗
PubMed1983

Nutritional assessment and preliminary report on early support of the trauma patient.

The high nitrogen demands imposed by severe trauma may quickly render the injured patient malnourished. Nutritional assessment of these patients is confused by tissue damage, shock, blood loss, operation, and anesthesia. Consequently, standard nutritional markers do not correlate well with immunocompetence and postoperative morbidity. For this reason we devised an abdominal trauma index (ATI) based on the anatomical severity of injury. The ATI is calculated by assigning a risk factor (1-5) to each organ injured and then multiplying this by a severity-of-injury estimate (1-5). The sum of the individual organ scores comprises the final ATI. The incidence of postlaparotomy complications is low (5%) with an ATI less than 15, intermediate (15%) with 15-25, and high (50%) with greater than 25. Having identified the high-risk trauma patient, we initiated a prospective randomized study to assess the cost-benefit of early nutritional support. Patients with an ATI greater than 15 were allocated to a control group (no supplemental nutrition during first five postoperative days) or enteral-fed group. The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy. The constant infusion of an elemental diet (Vivonex HN) was begun at 18 hours postoperatively and advanced to 3,000 cc/day within 72 hours. To date 26 patients (14 control, 12 enteral) have been entered in this study. At one week, nitrogen balance in the control group (-12.9 to -11.1 g/day) continues to be negative compared to a positive trend (-12.2 to +3.3 g/day) in the fed group. In control patients serum albumin (3.54 +/- 0.16 to 3.19 +/- 0.15 g%) and transferrin (227 +/- 11 to 204 +/- 10 mg%) decrease while in the enteral patients albumin (3.27 +/- 0.11 to 3.34 +/- 0.15 g%) and transferrin (229 +/- 10 to 234 +/- 12 mg%) remain stable. Although the incidence of overall morbidity is similar, septic complications occurred in 29% (4/14) of the control group compared to none in the enteral group. Our experience suggests the following: (1) Anatomical severity of injury is a better predictor of postinjury septic morbidity than standard nutritional markers; (2) immediate postoperative feeding by NCJ is safe and feasible; and (3) early nutritional support decreases the incidence of septic complications in the severely injured patient.

Abdominal Injuries↗
PubMed1981

Immediate jejunostomy feeding. Its use after major abdominal trauma.

Jejunostomy feedings were used in the immediate postoperative period in patients with massive abdominal and retroperitoneal injuries. Patients were selected for early feeding if they had two or more major visceral injuries. Over a six-month period, 30 such patients were studied: ten had blunt trauma, 11 had gunshot wounds, and nine had stab injuries. The injuries included 11 pancreatic, ten small-bowel, six colon, and six major retroperitoneal vascular injuries. A 16-gauge intracatheter was placed in the proximal jejunum. The constant infusion of nutritional solution (Vivonex HN) was begun 18 hours postoperatively, and within 72 hours all patients were receiving 2,400 calories per day. Feedings were maintained for an average of eight days. Serum albumin and transferrin levels, total lymphocyte count, and delayed hypersensitivity were maintained or improved during jejunal feeding. Patients with pancreatic injuries received supplemental nutrition without evidence of pancreatic stimulation. Needle-catheter jejunostomy can provide early, safe nutritional support after major abdominal trauma. Further investigation is needed to determine who will benefit from this early feeding.

Abdominal Injuries↗
PubMedDate not supplied

Factors influencing nutritional assessment in abdominal trauma patients.

Previous work has shown that an abdominal trauma index (ATI) based on anatomic severity of injury reliably predicts complications following abdominal trauma, whereas the Prognostic Nutritional Index (PNI) does not. This study was undertaken to reconcile the disparity between the PNI and ATI as predictors of postoperative morbidity and mortality. Twenty-four patients undergoing immediate laparotomy following acute abdominal trauma were evaluated. Their mean age was 32.8 years (range 18-59 years); 18 were men. All patients underwent nutritional assessment within 12 hours of surgery. A statistical comparison of blood replacement, operating time, ATI, and PNI was performed. The mean PNI was 51 and mean blood replacement was 12.5 units. Using linear regression the PNI and amount of blood replacement correlated significantly (r = 0..44, p less than 0.05). Operating time and ATI did not correlate with PNI. In conclusion, the PNI was more strongly influenced by blood loss than severity of intraperitoneal injury. For this reason it is relatively ineffective in predicting complications following trauma.

Abdominal Injuries↗
PubMedDate not supplied

Massive pneumatosis intestinalis and subcutaneous emphysema: complication of needle catheter jejunostomy.

The safety and efficacy of enteral feeding by needle catheter jejunostomy has prompted its use after many major gastrointestinal operations. Indeed, the technical complications of this procedure are infrequent. This report details the development of massive pneumatosis intestinalis associated with elemental feeding via jejunostomy. The proposed etiology includes excessive gas accumulation within the small intestine secondary to 1) inadequate nasogastric suction, 2) post-traumatic intestinal ileus, and 3) disaccharide fermentation; combined with a mucosal defect created by the catheter jejunostomy. Successful management consists of nasogastric suction and immediate termination of the enteral feeding.

Adult↗