Utility of esophageal gastroduodenoscopy at the time of percutaneous endoscopic gastrostomy in trauma patients

<p>Abstract</p> <p>Background</p> <p>The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons.</p> <p>Methods</p> <p>Retrospective review of all trauma patients undergoing EGD with PEG at a level I trauma center from 1/01–6/03.</p> <p>Results</p> <p>210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15 esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This finding led to a change in therapy in 90% of patients; either resumption/continuation of H₂-blockers or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient (1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local drainage and antibiotics, one requiring operative debridement and later closure, and one with antibiotics alone.</p> <p>Conclusion</p> <p>EGD at the time of PEG <b>may add </b>clinically useful data in the management of trauma patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with acceptable outcomes and complication rates.</p

Whole Farm Nutrient Balance Under Different Grazing Systems: Project Overview

The amount of phosphorus (P) in surface runoff from agricultural lands is of concern because of the potential for eutrophication of Iowa’s waterways. Currently, there is limited information about the total P loads in surface runoff coming from pastureland in the Midwest. Much of the P runoff is likely associated with sediment. Because foliage limits soil disruption caused by the impact of raindrops and because forage roots hold soil particles, forages harvested at an appropriate height, through suitable grazing management, should maintain water infiltration and minimize sediment and P loss in surface runoff from pastures. Grazing management may influence utilization of P by the animal, by impacting P digestibility. The objective of this project is to quantify P flows through systems operated under different grazing management practices. Figure 1 illustrates P inputs and outputs in the grazing system

Phosphorus, Crude Protein, and Digestible Dry Matter Concentrations of Forage Selected by Grazing Beef Cattle

Phosphorus (P) is an essential nutrient for beef cattle, but over-supplementation of P may have negative environmental and economic impacts. The P concentration in forage selected by grazing cattle may be sufficient to meet the nutritional requirements without supplementation. Similarly, the crude protein (CP) and in vitro digestible dry matter (IVDDM) concentration of forage selected by grazing cattle may be greater than available forage. This study was conducted to determine the P, CP, and IVDDM concentrations of forage selected by beef cattle grazing cool-season grass pastures. Fifteen fall-calving Angus cows were managed by either continuous or rotational stocking in 30-acre smooth bromegrass pastures, replicated twice. In July and August, one ruminally fistulated steer was placed in each pasture for one week. On two consecutive days at the end of each week, fistulated steers were ruminally evacuated, allowed to graze for 2 h, and sampled for forage selected during grazing. Forage samples were hand-clipped at ground level and from the upper half of the forage sward in pasture areas adjacent to the areas being grazed. A subsample of the ground-clipped forage was placed in the rumen and allowed to soak for 2 h following sampling of selected forage to correct the P, CP, and IVDDM concentrations in the selected forage for salivary P, CP, and IVDDM absorbed by selected forage. Hand-clipped and selected forage samples were analyzed for P, CP and IVDDM concentrations. Phosphorus concentrations in the available forage did not differ by month. However, P concentrations of available forage in continuously stocked pastures (0.22%) tended to be greater than in rotationally stocked pastures (0.20%). The P concentration of selected forage (0.39%) was almost twice as high as the available forage. Available forage in pastures managed by continuous stocking had greater CP and IVDDM concentrations than did forage in rotationally stocked pastures in both months. Results of this study show that cattle grazing cool-season grass pastures are able to select forage with an adequate crude protein and P concentrations to meet their nutrient requirement without supplementatio

Off-Stream Water, Shade and Nutritional Supplementation to Modify Animal Behavior

Another way to manage pasture water for positive water quality is to modify animal behavior. Find out about providing off-stream water, shade, and nutritional supplementation.https://lib.dr.iastate.edu/extension_ag_pubs/1224/thumbnail.jp

Impact of Grazing Management on Cattle Distribution and Physical Characteristics of the Riparian Zones of Pastures

Grazing management practices that allow cattle to congregate near pasture streams may result in the loss of vegetative cover and accumulation of manure near pasture streams. These conditions may cause loading of the streams with sediment, phosphorus, and pathogens carried in surface runoff. The loss of vegetation and increased compaction associated with concentrated cattle traffic may promote stream bank erosion causing further impairment of stream water quality. The objectives of the current study were 1) to evaluate cattle distribution patterns, in relation to a pasture stream/pond and 2)to evaluate the effects of stocking rate and the botanical composition of the pastures’ riparian zone on the forage sward height and the proportions of bare and manure-covered ground along the banks of pasture streams

Grazing Management of Beef Cows to Limit Non-point Source Pollution of Streams in Midwestern Pastures

In 2006, the Iowa DNR identified 336 impaired water bodies in Iowa. The majority of these impairments are associated with elevated nutrient, sediment, or bacterial loads in streams and lakes. Poorly managed grazing of beef cattle in riparian areas may contribute to a reduction in quality of Midwest surface waters. However, research has shown that management practices that alter the timing, frequency, duration, and timing of grazing can reduce the impact of cattle on water sources

Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

Introduction Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. Methods A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Results Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Conclusions Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery

Splenic Embolization Decreases Infectious Complications and Resource Utilization Compared to Splenectomy in Severely Injured Patients

Introduction. Increasing use of main coil angioembolization for splenic injury has raised concerns of increased complication rates and resource utilization compared to splenectomy. This study examined complication rates for severely injured patients undergoing splenectomy versus main coil angioembolization. Methods. Demographic data (age, sex, and race), Injury Severity Score (ISS), and splenic injury grade were collected prospectively on all patients admitted to the intensive care unit with blunt splenic injury treated with splenectomy or main coil angioembolization. Outcome measures (transfusion requirements, mechanical ventilation use and duration, mortality, intensive care unit and hospital length of stay, infection rate, and systemic inflammatory response syndrome or SIRS score) were reviewed daily. Results. Of 116 patients reviewed, 65 underwent splenectomy and 51 underwent main coil angioembolization. Groups were comparable for age, sex, race, and mechanism of injury. Splenectomized patients had a higher ISS (41 vs 31) and splenic injury grade (3.7 vs 3.2). The main coil angioembolization group had a lower transfusion requirement, hospital length of stay, incidence of mechanical ventilation, nosocomial infection rate, and SIRS score. Overall, mortality and ventilator days were lower but not statistically significant. Conclusions. Severely injured patients treated with splenectomy had significantly higher infection rates and resource utilization compared to those treated with main coil angioembolization

Computed Tomography in Trauma Patients Accepted in Transfer:: Missed Injuries and Rationale for Repeat Imaging. Can we do Better?

Introduction. Computed tomography scans often are repeated ontrauma patient transfers, leading to increased radiation exposure,resource utilization, and costs. This study examined the incidenceof repeated computed tomography scans (RCT) in trauma patienttransfers before and after software upgrades, physician education,and encouragement to reduce RCT.Methods.xThe number of RCTs at an American College of SurgeonsCommittee on Trauma verified level 1 trauma center was measured.The trauma team was educated and encouraged to use the computedtomography scans received with transfer trauma patients as perstudy protocol. All available images were reviewed and reasons for aRCT when ordered were recorded and categorized. Impact of systemimprovements and education on subsequent RCT were evaluated.Results. A RCT was done on 47.2% (n = 76) of patients throughoutthe study period. Unacceptable image quality and possible misseddiagnoses were the most commonly reported reasons for a RCT. Preventablereasons for a RCT (attending refusal to read outside films,incompatible software, and physician preference) decreased from25.8 to 14.3% over the study periods.Conclusions. The volume of unnecessary RCT can be reduced primarilythrough software updates and physician education, therebydecreasing radiation exposure, patient cost, and inefficiencies in hospitalresource usage. Kans J Med 2019;12(1):7-10