Objective:The purpose of this retrospective study was to evaluate maternal and perinatal outcomes and complications of parenteral nutrition during pregnancy in our institution. Mehods:This study was a review of medical records of all women who required parenteral nutrition during pregnancy at our institution from 1990-1997. The frequency of maternal and perinatal complications was calculated. Resulb: Twenty-six pregnancies required parenteral nutrition for the following indications: hyperemesis gravidarum (n = 16), cholecystitis/pancreatitis ( n = 3 ) , small bowel obstruction (n = 2), intracranial bleed (n = 2), ulcerative colitis (n = l ) , and other (n = 2). The mean gestational age at initiation of therapy was 16.2 weeks and the mean duration of therapy was 30.6 days. Five pregnancies were terminated prior to fetal viability. O f the remaining pregnancies, obstetric complications occurred in 1 1, including two cases of idiopathic preterm labor resulting in preterm deliveries. Maternal complications resulting from the central venous catheters included four infections, two thromboses, one occlusion, one pneumothorax, and one catheter dislodgment. The complication rate for centrally inserted central catheters (50%) was significantly greater than the rate for peripherally inserted central catheters (9%). Conclusions: Successful outcomes can be achieved in obstetric patients requiring parenteral nutrition. In this group of patients, the frequency of maternal complications secondary to centrally inserted central venous catheters was greater than that reported in nonpregnant patients. Peripherally inserted central catheters may be preferable when parenteral nutrition is required during pregnancy. 1. Matem-Fetal Med. f999;8: 164-1 67. 0 1999 Wiley-Liss, Inc.
Parenteral nutrition (PN) is one of the most sophisticated forms of intravenous therapy in use today. Intravenous feeding is a life-saving technology for patients unable to maintain their nutritional status using the gastrointestinal tract. Although PN has become an integral component of patient care, the risks associated with this therapy must be weighed against the potential benefits. Comprehensive clinical management includes selection of candidates, implementation and monitoring of therapy, and ensuring a seamless transition when PN is no longer required. Optimal parenteral nutrition demands expertise in caring for vascular access devices. A collaborative approach to care minimizes the risks associated with PN and ensures positive patient outcomes.
Integrin alpha6beta4 is altered in many neoplastic cells, but no data exist to show this happens in esophageal neoplasms. To examine the expression of this integrin in rat esophageal tumorigenesis induced by N-nitrosomethylbenzylamine (NMBA), (alpha6 and beta4 expression was evaluated in normal esophageal epithelium, in NMBA-induced preneoplastic lesions, and in papillomas by quantitative reverse transcription (RT)-polymerase chain reaction (PCR) and immunohistochemical analysis. Because the 34 subunit of this integrin has been found to cause cell-cycle arrest by the induction of p21/WAF1/Cip1, the expression of p21/WAF1/Cip1 was also analyzed by RT-PCR. Compared with the levels in normal epithelium, the alpha6A, alpha6B, and beta4 integrin levels in esophageal papillomas were 1.9-, 2.2-, and 2.1-fold lower, respectively. RT-PCR analysis showed no significant differences in integrin levels between preneoplastic and normal samples, and northern blot analysis of the beta4 integrin produced results in agreement with the RT-PCR results. The p21/WAF1/Cip1 level was decreased 1.6-fold in preneoplastic tissues and 3.1-fold in papilloma samples when compared with the mRNA levels in normal epithelium. Immunostaining showed that alpha6beta4 integrin was localized at the basolateral surface of the basal cells in normal esophageal epithelium. In preneoplastic lesions, however, the expression of this integrin was not polarized and was expressed in basal cells as well as in suprabasal cells. Beta4 expression was significantly reduced and alpha6A expression was decreased and delocalized in papillomas. These findings suggest that alteration in alpha6beta4 integrin and p21/WAF1/Cip1 expression may be an important biomarker for tumor progression in NMBA-induced rat esophageal tumorigenesis.
Hyperemesis gravidarum (HG) was once a major cause of maternal mortality. The impact of prolonged and severe nausea and vomiting on the fetus and mother can be devastating. Disturbances in fluid, electrolyte, and acid-base balances are common. The reduction in maternal deaths associated with HG is a result of improved understanding and more aggressive treatment of these metabolic alterations. HG is the most common reason for nutrition support intervention during pregnancy. However, little information is available regarding the nutritional issues associated with HG or the effects of providing nutrition support on pregnancy outcome. This review discusses the nutritional implications of HG and strategies for clinical management, including hydration, pharmacologic therapies, and the provision of enteral and parenteral nutrition. Implications for home care and future research are also presented. Nausea and vomiting occur commonly during early pregnancy, affecting 50% to 90% of women.' In general, nausea and vomiting in pregnancy, frequently referred to as "morning sickness," begins between the 4th and 7th week of pregnancy. For the majority of women; these symptoms peak by the 12th week and nutritional deficiencies including weight loss generally do not occur.' A more severe form of nausea and vomiting, hyperemesis gravidarum (HG), occurs in <1% of pregnancies. Clinical features of HG include persistent vomiting that occurs for the first time before the 20th week of gestation, weight loss greater than 5% of prepregnancy weight, fluid and electrolyte alterations, acidCorrespondence and reprint requests: Beth A. Wagner, RN, hISN, CNSN, 50 Nonvich Dr., Sewell, NJ 08080. Electronic mail may be sent to hemwagnefiaol.com. for P a r e n t e d and Enteral Nutrition base disturbances, and ketonuria. Definitions of I t typically include a statement that the condition requires hospitalization. However, the current trend for reducing hospital admissions combined with clinical advances in home care practice allow safe and effective provision of fluids, electrolytes, antiemetics, and nutrition support at home.3,4,5*6The etiology of nausea and vomiting during pregnancy remains unclear, although numerous theories exist. Proposed mechanisms include elevated levels of gestational hormones, gastrointestinal abnormalities, thyroid dysfunction, psychological and social factors, and fetal anomalies. The role of psychological processes as a causative factor in HG is unsubstantiated. It is not clear whether the emotional conditions that are associated with HG such as tearfulness, infantile or immature personality, irritability, sleep disturbance, and anxiety or depression are simply triggered by the stress of severe illness, rather than a causative f a~t o r .~ Risk factors for the development of HG include nulliparity, HG in a prior pregnancy, increased body weight, and multiple gestations.'HG is a diagnosis of exclusion. The patient evaluation must exclude the possibility of other disorders, including hepatobiliary disease, pancreatitis, p...
Integrin alpha6beta4 is altered in many neoplastic cells, but no data exist to show this happens in esophageal neoplasms. To examine the expression of this integrin in rat esophageal tumorigenesis induced by N-nitrosomethylbenzylamine (NMBA), (alpha6 and beta4 expression was evaluated in normal esophageal epithelium, in NMBA-induced preneoplastic lesions, and in papillomas by quantitative reverse transcription (RT)-polymerase chain reaction (PCR) and immunohistochemical analysis. Because the 34 subunit of this integrin has been found to cause cell-cycle arrest by the induction of p21/WAF1/Cip1, the expression of p21/WAF1/Cip1 was also analyzed by RT-PCR. Compared with the levels in normal epithelium, the alpha6A, alpha6B, and beta4 integrin levels in esophageal papillomas were 1.9-, 2.2-, and 2.1-fold lower, respectively. RT-PCR analysis showed no significant differences in integrin levels between preneoplastic and normal samples, and northern blot analysis of the beta4 integrin produced results in agreement with the RT-PCR results. The p21/WAF1/Cip1 level was decreased 1.6-fold in preneoplastic tissues and 3.1-fold in papilloma samples when compared with the mRNA levels in normal epithelium. Immunostaining showed that alpha6beta4 integrin was localized at the basolateral surface of the basal cells in normal esophageal epithelium. In preneoplastic lesions, however, the expression of this integrin was not polarized and was expressed in basal cells as well as in suprabasal cells. Beta4 expression was significantly reduced and alpha6A expression was decreased and delocalized in papillomas. These findings suggest that alteration in alpha6beta4 integrin and p21/WAF1/Cip1 expression may be an important biomarker for tumor progression in NMBA-induced rat esophageal tumorigenesis.
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