PEG (percutaneous endoscopic gastrostomy) tubes are frequently placed in nursing home patients. The aim of this study was to assess retrospectively the long-term changes in functional and nutritional statuses, tube-related complications, and factors influencing survival in 46 nursing home residents, mean age 73.6 years (range 19-96). Functional status was evaluated by a standard rehabilitation medicine scale. Nutritional status was evaluated by serum albumin and cholesterol concentrations and by weight. PEG-related complications requiring hospitalization or emergency room or clinic evaluations were noted. Additionally, changes in resuscitation status were noted. The predominant indication for PEG placement was dementia (52%). At PEG placement, 48% of patients had total functional impairment. Regardless of the severity of impairment, no patient's functional status improved after PEG. Nutritional status did not improve significantly. Mortality approached 50% and 60% at 12 and 18 months, respectively, and was significantly related to age, resuscitation status, and serum albumin concentration. All patients under 40 years of age at PEG survived, in contrast to 41.3% of patients over 40 years of age (P < 0.001). Sixty-three percent of patients who were "full code" at PEG placement survived, in contrast to 10% of "no code" patients (P < 0.001). Albumin > or = 3.5 g/dl at PEG or thereafter was associated with improved survival (P < 0.001) as compared to albumin < 3.5 g/dl. PEG-related complications occurred in 34.7% of patients, and the first occurred four months after PEG. We conclude that realistic expectations of what PEG can accomplish be a factor in the decision to place a PEG tube in nursing home patients.
Misrepresentation on applications for gastroenterology fellowships was common. The following steps are recommended: 1) Fellowship programs should require that copies of all publications and letters of acceptance for manuscripts in press be submitted with fellowship applications; 2) applications should contain a statement to be signed by the applicant that the information provided is accurate; 3) persons writing letters of recommendation should verify the information being submitted by applicants; 4) medical students and residents should be taught that embellishment of curricula vitae constitutes misconduct; and 5) institutions and professional organizations should develop policies to deal with this problem.
We have investigated whether hepatic peroxisomes are capable of synthesizing carnitine. When purified peroxisomes were incubated with y-butyrobetaine, a precursor of carnitine, formation of carnitine was observed. These results indicate that peroxisomes contain y-butyrobetaine hydroxylase, the enzyme which catalyzes the final step in the biosynthesis of carnitine. This enzyme was previously believed to be present only in the cytosol. y-Butyrobetaine hydroxylase activity in peroxisomes was not due to cytosolic contamination as evaluated by marker enzyme analysis. When proliferation of peroxisomes was induced by clofibrate treatment, y-butyrobetaine hydroxylase/mass liver increased by 7.6-fold and the specific activity by 2.5-fold. We conclude that hepatic peroxisomes synthesize carnitine and this synthesis becomes substantial under conditions of peroxisomal proliferation.Peroxisomes were long believed to have only a minor role in mammalian metabolism; however, in recent years, it has become clear that these organelles perform many diverse metabolic functions. It is not known whether peroxisomes are capable of synthesizing carnitine. The importance of this information is underscored by the fact that peroxisomes oxidize fatty acids, particularly the very-long-chain fatty acids (> CIS), and require the participation of carnitine [7 -91. The oxidation of fatty acids in peroxisomes is not complete, but terminates a t acyl-CoA residues of medium-chain length [8]. These acylCoA residues, as well as acetyl-CoA produced by P-oxidation, are then transported out of peroxisomes as acylcarnitines for further metabolism (Fig. 1) [9-121. Formation of acylcarnitines is catalyzed by carnitine acyltransferases, enzymes located in peroxisomes which utilize carnitine as a substrate [8, 131. Therefore, peroxisomal metabolism of fatty acids requires a substantial amount of carnitine. For example, peroxisomal metabolism of one mole of palmitoyl-CoA may require up to five moles of carnitine (Fig. 1).The source of carnitine for peroxisomal metabolism of fatty acids is not known. In the present study we have investigated the possibility of the synthesis of carnitine in per-C'orrespondence lo H.
The prevalence of clinically relevant bacteremia after endoscopic procedures in bone marrow transplant recipients was assessed retrospectively. Bacteremia, within 24 hr of procedure, was defined as positive blood cultures, while hypotension and temperature greater than 38 degrees C were taken as possible indicators of bacteremia. Sixty-seven procedures were performed in 53 endoscopic sessions (upper endoscopy 37, flexible sigmoidoscopy 7, upper endoscopy + flexible sigmoidoscopy 8, colonoscopy 1). Twenty-five endoscopic sessions were performed in patients receiving broad-spectrum antibiotics and 28 sessions in patients not receiving antibiotics. Both groups were comparable with respect to patient characteristics, procedures performed, and immune status. No patient in either group developed hypotension. One patient developed fever after flexible sigmoidoscopy; no source of fever was identified. We conclude that: (1) there were no episodes of clinically relevant bacteremia attributable to endoscopic procedures, and (2) not all bone marrow transplant recipients require routine antibiotic prophylaxis prior to endoscopic procedures.
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