Randomised clinical trial: Polyethylene glycol 3350 with sports drink vs. polyethylene glycol with electrolyte solution as purgatives for colonoscopy--the incidence of hyponatraemia

BACKGROUND

Polyethylene glycol 3350 plus sports drink (PEG-SD) is a hypo-osmotic purgative commonly used for colonoscopy, though little safety data are available.

AIM

To evaluate the effect of PEG-SD on serum sodium (Na) and other electrolytes compared with PEG-electrolyte solution (PEG-ELS).

METHODS

We performed a single center, prospective, randomised, investigator-blind comparison of PEG-ELS to PEG-SD in out-patients undergoing colonoscopy. Laboratories were obtained at baseline and immediately before and after colonoscopy. The primary endpoint was development of hyponatraemia (Na <135 mmol/L) the day of colonoscopy. Changes in electrolyte levels were computed as the difference between the lowest value on the day of colonoscopy and baseline. Purgative tolerance and efficacy were assessed.

RESULTS

A total of 389 patients were randomised; 364 took purgative and had baseline and day of colonoscopy labs (180 PEG-SD, 184 PEG-ELS). The groups were well matched except for a higher fraction of women and Blacks in PEG-ELS. Seven patients (3.9%) in PEG-SD and four patients (2.2%) in PEG-ELS developed hyponatraemia (OR = 1.82, 95% CI: 0.45-8.62, P = 0.376). Changes in electrolytes from baseline were small but significantly worse with PEG-SD for sodium, potassium and chloride (P = 0.001, 0.012, 0.001, respectively). Preparation completion, adverse events, and overall colon cleansing were similar between the groups, but PEG-ELS had more excellent preparations (52% vs. 30%; P = 0.001).

CONCLUSIONS

Greater, but very modest, electrolyte changes occur with PEG-SD. Hyponatraemia is infrequent with both purgatives. A significant increase in hyponatraemia was not identified for PEG-SD vs. PEG-ELS, but the sample size may have been inadequate to identify a small, but clinically important difference. ClinicalTrials.gov identifier NCT01299779.

Change in Colorectal Cancer Screening Decision Stage

Introduction: Colorectal cancer screening (CRC) screening decision stage (SDS) is a measure of proximity to screening. Predictors of change in SDS have not been reported in the literature.

Objective: To assess SDS change and predictors of SDS among primary care patients 50 to 74 years of age who are enrolled in a randomized, controlled trial of behavioral interventions designed to increase CRC screening.

Methods: On a baseline survey, study participants reported on perceptions about CRC screening and SDS (i.e., decided to screen vs. had not decided to screen). Participants were randomized to one of three study groups: Control Group (usual care), Standard Intervention (SI) Group [mailed screening materials (i.e., informational booklet, a stool blood test kit, instructions for scheduling a screening colonoscopy, and a reminder)]; and a Tailored Navigation Intervention (TNI) Group (mailed screening materials tailored to baseline SDS and a navigation telephone call). TNI Group participants were asked to report current SDS, including current screening status, at navigation. We assessed change in SDS from baseline to navigation and performed multivariable analyses to identify predictors of SDS change.

Results: Of 248 TNI Group participants, 205 (83%) received a navigation call. Background characteristics of these participants were as follows: white (76%), female (64%), aged 50–59 (67%), &gt;high school education (52%), and married (62%). At baseline, 43 (21%) participants reported that they had not decided to screen, and 162 (79%) reported that they had decided to screen. At navigation, 55 (27%) participants reported a positive change in SDS (26 moved forward in SDS but did not screen and 29 screened). Participants who had not decided to screen at baseline were more likely to exhibit positive change in SDS than those who had decided to screen at baseline (63% and 17%, respectively, P &lt; 0.0001). Among participants who had not decided to screen at baseline, only one reported actual screening. Of those participants who had decided to screen, 28 actually screened.

Discussion: More than a quarter of participants reported a positive change in SDS in response to the mailed tailored intervention materials sent before the navigation call. Baseline SDS was a strong predictor of SDS change.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up

BACKGROUND AND HYPOTHESIS

The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms.

METHODS

We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months.

RESULTS

Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008).

CONCLUSIONS

Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

Factors associated with mental health, general health, and school-based service use for child psychopathology

OBJECTIVES

This study was designed to identify factors associated with service use for child psychopathology in three settings: mental health, general health, and school.

METHODS

Subjects were 2519 children, 6 to 11 years of age, assessed in two cross-sectional Connecticut surveys in the late 1980s. Three groups of variables (sociodemographics, child's illness profile, and parental attitudes) were examined through multivariate logistic regression.

RESULTS

Most sociodemographics showed moderate associations with all settings, although some previously reported effects (e.g. birth order, sibship size) were not observed. Of the illness profile measures, only Child Behavior Checklist total scores predicted use in the final model (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.1, 2.3). Health problems were associated with increased use in all settings (OR = 1.5, 95% CI = 1.3, 1.9), while academic problems were associated only with increased school service use (OR = 5.2, 95% CI = 3.9, 7.0). Parental belief that the child needed help was most strongly associated with service use (common OR for all settings = 5.3, 95% CI = 4.1, 6.8).

CONCLUSIONS

Sociodemographics, parental attitudes, and children's illness profiles independently influence service use for psychopathology in school-aged children.

A regression approach to the analysis of serial peak flow among fuel oil ash exposed workers

We investigated the association between exposure to fuel oil ash and acute airway obstruction in 31 boilermakers and 31 utility workers during the overhaul of a large oil-fired boiler. Air flow was assessed with self-recorded serial peak expiratory flow rate measurements (PEFR) using a mini-Wright meter. Exposure to thoracic particulates with an aerodynamic diameter of 10 gm or smaller (PM10) was assessed using personal sampling devices and detailed work diaries. All subjects were male, with an average age of 43 yr, and an average of 18 yr at their current trade. Average PM10 exposure on work days was 2.75 mg/m3 for boilermakers and 0.57 mg/m3 for utility workers. Three daily PEFR measurements (start-of-shift, end-of-shift, and bed-time) were analyzed simultaneously, using Huber linear regression. After adjustment for job title, welder status, age, height, smoking, and weld-years, for each mg/m3 increase in PM10, the estimated decline in PEFR was 13.2 L/min (p = 0.008) for end-of-shift, 9.9 L/min (p = 0.045) for bed-time, and 6.6 L/min (p = 0.26) for start-of-shift of the following day. This decline of the exposure effect over the 24-h period that follows was statistically significant (p = 0.004). No other factors were found to significantly modify the effect of exposure. Our results suggest that occupational exposure to fuel oil ash is associated with significant acute decrements in peak flow.

Left-ventricular hypertrophy in the elderly: unreliability of ECG criteria in 477 subjects aged 65 years or more. The CArdiovascular STudy in the ELderly (CASTEL)

AIM

To evaluate the diagnostic reliability of the ECG diagnosis of left-ventricular hypertrophy (LVH) in a cohort of elderly subjects taken from a general population.

PATIENTS

The 447 subjects with perfect echocardiography and ECG results of the 2,254 included in the Cardiovascular Study in the Elderly.

METHODS

Sensitivity, specificity, positive and negative predictive value of the most commonly used ECG tests of LVH were calculated versus the gold standard, echocardiography.

RESULTS

All ECG tests had a very low sensitivity. Furthermore, except for the Cornell index and (at least in the normotensives) the Minnesota code, they were not able to demonstrate the higher prevalence of LVH in elderly females in comparison to males. The predictive value of ECG was constantly higher in males than females when negative; when positive, some tests were more predictive in males, some in females, and in others, equally predictive in both sexes.

CONCLUSIONS

ECG is not a reliable method for screening LVH in elderly populations. Echocardiography and ECG give different information, and their reliability may be different if positive or negative.

Bivariate logistic regression analysis of childhood psychopathology ratings using multiple informants

A central issue in studies of risk factors for childhood psychopathology is utilization of the information obtained about the child's mental health status from multiple informants. In this paper, the authors propose a new approach to the analysis of risk factor data when the outcomes are binary ratings (presence/absence of symptoms). This new approach has several attractive features in this setting. The strategy taken is to perform a single analysis using multivariate modeling, in which simultaneous logistic regressions are conducted for the outcomes given by each of several informants. The advantages of this approach include the following: 1) it retains the complete information about case status for each informant; 2) it permits assessment of informant-risk factor interactions as well as "overall" risk factor effects; 3) it provides measures of association between the multiple informants and adjusts for the association between responses in the analysis; and 4) missing data on a subset of respondents can be incorporated in a straightforward way, permitting all subjects with at least one informant to be used in the analysis. To illustrate the methods, the authors present findings on risk factors for measures of "Internalizing" and "Externalizing" behaviors from two surveys using parent and teacher ratings of 6- to 11-year-old children in Connecticut between 1986 and 1989.

Mortality in relation to Minnesota code items in elderly subjects. Sex-related differences in a cardiovascular study in the elderly

The prognostic value of electrocardiographic abnormalities has not been widely studied in the elderly. We examined the Minnesota code ECG items in 2254 elderly subjects of the Cardiovascular Study in the Elderly (CASTEL), performed on an Italian general population. In our experience, codes for ischaemia, 1st-degree atrio-ventricular block, bundle branch blocks, myocardial infarction, atrial fibrillation or sinus tachycardia were predictors of overall mortality in females, while only the former three items were predictors in men. Although ischaemia, left bundle branch block and atrial fibrillation were predictors of cardiovascular mortality in both sexes, right bundle branch block, supraventricular arrhythmias and left ventricular hypertrophy were predictors only in men, and 1st-degree atrio-ventricular block were predictors only in women. Surprisingly, left anterior haemiblock and bifascicular blocks were not predictive of mortality.

Blood pressure, left ventricular hypertrophy and diabetes among 179 very old hypertensives from an Italian general population. The CASTEL (Cardiovascular Study in the Elderly)

Hypertension is common in elderly subjects, but old and particularly very old people have usually been excluded from major epidemiological trials. We studied 179 hypertensive subjects aged 80 years or more drawn from elderly people of an Italian town within the context of the CASTEL (Cardiovascular Study in the Elderly). Prevalence of hypertension declined from 66.7% (first visit, first measurement) to 56.3% (last visit, last measurement). Systolic but not diastolic blood pressure was a little higher among very old hyperglycemic hypertensive subjects than in normoglycemic ones, while left ventricular mass was independent of both blood pressure and glucose intolerance.

Comparison of patients' and their resident physicians' responses regarding smoking-cessation interventions

PURPOSE

To investigate (1) the extent of agreement between what resident physicians and their patients report as having occurred in physician-delivered smoking interventions and (2) the ability of residents to effectively transmit information concerning smoking interventions to their patients.

METHODS

A total of 263 patients and 91 residents in internal medicine or family practice completed paper-and-pencil exit interviews after a regularly scheduled clinic appointment between 1986 and 1988 at the University of Massachusetts Medical School; the residents had been trained to deliver counseling interventions. The kappa statistic was used as an index of chance-corrected agreement between the patients' and residents' responses.

RESULTS

Agreement was substantial regarding whether a specific plan for the patient to stop or reduce smoking was agreed upon, whether written materials on how to quit smoking were provided, and whether nicotine-containing chewing gum was prescribed.

CONCLUSIONS

There was positive agreement between the patients and their resident physicians concerning the residents' delivery of quit-smoking messages and the provision of written materials to assist in stopping. Programs must continue to be designed, for residents and for more senior physicians, so that physicians can be encouraged to incorporate smoking interventions into their practice activities.

[Hemodynamic effects of "expresso" Italian coffee and pure caffeine on healthy volunteers]

In 15 healthy non-coffee-drinker subjects and in 5 usual coffee-drinkers, the effects were studied of 2 cups of "espresso" italian coffee and of 200 mg purified caffeine on blood pressure, heart rate, forearm rest flow and peripheral resistance. In the 15 non-coffee-drinkers, left ventricular ejection fraction, fractional shortening, cardiac output and end-systolic stress were also evaluated by a 2D-guided M-mode echocardiogram before and 60 and 120 min after oral administration of 200 mg purified caffeine. In the non-coffee-drinker volunteers, diastolic and systolic blood pressure and peripheral resistance increased both after "espresso" coffee and after caffeine. In the usual drinkers no hemodynamic effect was seen. No variation of cardiac contractility was observed. We conclude that caffeine contained in the "espresso" coffee obtained with the high-pressure italian procedure is a strong vasoconstrictor agent, while it has no action on cardiac contractility.