Development of an Emergency Department Surge Plan Based on the NEDOCS score

Context: Emergency Department (ED) overcrowding is a significant problem worldwide. Many factors contribute to ED overcrowding, including staffing shortages, diagnostic testing delays, and inadequate inpatient beds to meet the demand. ED overcrowding results in patient safety issues like higher inpatient mortality and other negative impacts, such as an increased length of stay (LOS) and an increased trend of leaving the ED before undergoing an evaluation and treatment. The National emergency department overcrowding study (NEDOCS) is a scoring system to detect ED overcrowding objectively. Objective: To determine the impact of implementing an ED adult surge plan on ED throughput. Study Design: Prospective single-site study of adults presenting to the ED from January to April 2023. Setting or Dataset: Academic medical center. Population studied: Adult ED patients. Outcome Measures: Mean adult ED hold times, mean ED LOS, left without seen rate, mean door-to-doctor exam time, mean NEDOCS scores. Results: This analysis included 16,701 ED visits and 12,269 patients. During this time, 3,751 (22.5%) patients were admitted to inpatient status, and 1,413 (8.5%) were admitted to observation status. Pre-implementation, the mean ED hold time was 9.9 hours which decreased to 5.7 hours post-implementation (p=0.03). Pre-implementation, the mean ED LOS was 15.4 hours which decreased to 14.1 hours post-implementation (p=ns). Pre-implementation, the left without being seen rate was 4.8%, which decreased to 4.0% post-implementation (p=ns). Pre-implementation, the mean door-to-doctor exam time was 57.6 minutes which decreased to 54.0 minutes postimplementation (p=ns). Pre-implementation, the mean NEDOCS score was 186.2, which decreased to 131.2 post-implementation (p<0.0001). Conclusions: Our study suggests that implementing an ED adult surge plan can significantly improve ED hold hours and NEDOCS scores. However, it is important to note that other important ED throughput metrics (mean ED LOS, left without seen rate, mean door-to-doctor exam time) did not significantly improve. Further research may be necessary to understand the factors contributing to these outcomes and identify additional interventions that may improve ED throughput.

Clinical Outcomes of a Newly Instituted Hospital at Home Program During the COVID19 Pandemic

Context: The COVID19 pandemic stressed U.S. health systems beyond their capacity and created worsening clinical outcomes. Hospital a Home (HaH) programs were utilized infrequently prior to pandemic. The Acute Care at Home Waiver was introduced in 2020 to facilitate the creation of HaH programs with a goal of promoting treatment in the home setting. A potential alternative approach to creating rapid inpatient level health system capacity is providing hospital-level care at home to substitute for inpatient hospitalization. The overall impact on clinical outcomes of a HaH program in patients with COVID19 is not well understood. Objective: To compare clinical outcomes of a HaH program versus usual hospital care for patients admitted for COVID19. Study Design: Matched case-control retrospective chart review. Setting or Dataset: Academic medical center. Population studied: Patients admitted with COVID19 and subsequently enrolled into the HaH program from February 1, 2021 to January 31, 2022. Patients aged <18 were excluded from consideration for enrollment. A case-control sample was matched on age, gender, and severity of illness. A total of 200 patients (100 HaH and 100 control) were included for analysis. Outcome Measures: Primary outcome: 30-day readmissions, Secondary outcomes: Inpatient length of stay (iLOS) defined as length of stay in the physical hospital, total length of stay (tLOS) (sum of iLOS and HaH program days), time to readmission, and 30-day emergency department visits. Results: Analysis included 200 patents. The mean age was 50.4. The sample was 55% female. 48.5% were black, 43.5% were white, and 8% were other races. Compared with usual care patients, HaH patients had no difference in 30-day readmissions (11% vs. 14%, p=0.648), mean days to readmission (9.0 vs. 11.8, p=0.201), or return ED visits (17% vs. 20%, p=0.701). Inpatient LOS (5.7 vs. 9.4 days, p=0.005) was shorter in the HaH group. Total LOS (13.0 vs. 9.4 days, p<0. 001) was longer in the HaH group. Conclusions: The HaH program was associated with no difference in readmissions, time to readmission, or return ED visits compared to usual hospital care. HaH programs were associated with shorter inpatient length of stays, but longer total length of stays. In surge times, HaH programs could potentially reduce iLOS and increase bed capacity. Future studies should look to evaluate the economic impact of HaH programs and investigate the drivers of the increased tLOS.

Upper Gastrointestinal Bleeding in Adults: Evaluation and Management

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data.

Hepatitis B: Screening, Prevention, Diagnosis, and Treatment

Hepatitis B virus (HBV) is a partly double-stranded DNA virus that causes acute and chronic liver infection. Screening for hepatitis B is recommended in pregnant women at their first prenatal visit and in adolescents and adults at high risk of chronic infection. Hepatitis B vaccination is recommended for medically stable infants weighing 2,000 g or more within 24 hours of birth, unvaccinated infants and children, and unvaccinated adults requesting protection from hepatitis B or who are at increased risk of infection. Acute hepatitis B is defined as the discrete onset of symptoms, the presence of jaundice or elevated serum alanine transaminase levels, and test results showing hepatitis B surface antigen and hepatitis B core antigen. There is no evidence that antiviral treatment is effective for acute hepatitis B. Chronic hepatitis B is defined as the persistence of hepatitis B surface antigen for more than six months. Individuals with chronic hepatitis B are at risk of hepatocellular carcinoma and cirrhosis, but morbidity and mortality are reduced with adequate treatment. Determining the stage of liver disease (e.g., evidence of inflammation, fibrosis) is important to guide therapeutic decisions and the need for surveillance for hepatocellular carcinoma. Treatment should be individualized based on clinical and laboratory characteristics and the risks of developing cirrhosis and hepatocellular carcinoma. Immunologic cure, defined as the loss of hepatitis B surface antigen with sustained HBV DNA suppression, is attainable with current drug therapies that suppress HBV DNA replication and improve liver inflammation and fibrosis. Pegylated interferon alfa-2a, entecavir, and tenofovir are recommended as first-line treatment options for chronic hepatitis B.

Patient-Centered Medical Home Status and Preparedness to Assess Resident Milestones: A CERA Study

Purpose

The patient-centered medical home (PCMH) model has been proposed as the ideal model for delivering primary care and is focused on improving patient safety and quality, reducing costs, and enhancing patient satisfaction. The mandated Accreditation Council for Graduate Medical Education educational milestones for evaluation of resident competency represent the skills graduates will utilize after graduation. Many of these skills are reflected in the PCMH model. We sought to determine if residency programs whose main family medicine (FM) practice sites have achieved PCMH recognition are therefore more prepared to evaluate milestones.

Method

A national Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine program directors (PDs) was conducted during June and July 2015 to determine if PCMH recognition influences PDs' ability to evaluate training methods and their level of preparedness to evaluate milestones.

Results

The response rate for the survey was 53.3% (252/473). Nearly two-thirds of the PDs (62.7%) reported that their main FM practice site had earned PCMH recognition. There was no statistical difference between non-PCMH-recognized vs PCMH-recognized programs in how PDs perceived that their program was prepared to assess residents' milestone levels overall (P=0.414). Residents of PCMH-recognized programs were more likely to receive training for team-based care (P=0.009), system improvement plans (P<0.001), root-cause analysis (P=0.002), and health behavior change (P=0.003).

Conclusions

PCMH recognition itself did not improve preparedness of FM residency programs to assess milestones. Residents from programs whose main FM practice site is PCMH-recognized are more likely to be trained in the key concepts and tasks associated with the PCMH model, tools that they are expected to utilize extensively after graduation.

Colorectal Cancer Screening and Prevention

Colorectal cancer is a common cause of morbidity and mortality in the United States. Most colorectal cancers arise from preexisting adenomatous or serrated polyps. The incidence and mortality of colorectal cancer can be reduced with screening of average-risk adults 50 to 75 years of age. Randomized controlled trials show evidence of reduced colorectal cancer-specific mortality with guaiac-based fecal occult blood tests and flexible sigmoidoscopy. There are no randomized controlled trials on the effectiveness of colonoscopy to reduce colorectal cancer-specific mortality; however, several randomized controlled trials comparing colonoscopy with other strategies are in progress. The best available evidence supporting colonoscopy is from prospective cohort studies that demonstrate decreased incidence of colorectal cancer and colorectal cancer-related mortality in individuals undergoing colonoscopy. Other screening options include fecal immunochemical testing, computed tomographic colonography, and multitargeted stool DNA testing combined with fecal immunochemical testing. There is good evidence that aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and hormone therapy decrease the risk of colorectal cancer and adenomatous polyps, but potential harms limit their usefulness. There is good evidence that calcium supplementation, moderate dairy consumption, reduced red meat consumption, increased physical activity, decreased body mass index, and statin use decrease the risk of colorectal cancer and adenomatous polyps. Although increased alcohol intake and tobacco use are associated with an increased risk of colorectal cancer, there is no direct evidence that reducing alcohol consumption or smoking cessation decreases the risk.

Use of a web portal by adult patients with pre-diabetes and type 2 diabetes mellitus seen in a family medicine outpatient clinic

Background

There has been increasing interest in the use of web portals by patients with type 2 diabetes mellitus (T2DM). Studies of web portal use by patients with pre-diabetes have not been reported. To plan studies of web portal use by adult clinic patients seen for pre-diabetes and T2DM at an academic medical center, we examined characteristics of those who had or had not registered for a web portal.

Methods

Electronic records were reviewed to identify web portal registration by patients treated for pre-diabetes or T2DM by age, sex, race and ethnicity.

Results

A total of 866 patients with pre-diabetes and 2,376 patients with T2DM were seen in a family medicine outpatient clinic. About 41.5% of patients with pre-diabetes and 34.7% of those with T2DM had registered for the web portal. In logistic regression analysis, web portal registration among patients with T2DM was significantly associated with age 41-45 years, and with Hispanic ethnicity. Similar results were obtained for pre-diabetes except that the positive association with age 41-45 years and inverse association with Hispanic ethnicity were not statistically significant. Among patients with pre-diabetes or T2DM, Black men and Black women were less likely to have registered than their white counterparts. Patients who were aged 18-25 and >65 years were less likely to have registered for the web portal than those 26-65 years.

Conclusions

Additional research is needed to identify portal design features that improve health outcomes for patients with pre-diabetes and T2DM and interventions that will increase use of patient portals by pre-diabetic and diabetic patients, especially among Black patients and older patients.

Colorectal Cancer Screening and Surveillance in Individuals at Increased Risk

Individuals at increased risk of developing colorectal cancer include those with a personal or family history of advanced adenomas or colorectal cancer, a personal history of inflammatory bowel disease, or genetic polyposis syndromes. In general, these persons should undergo more frequent or earlier testing than individuals at average risk. Individuals who have a first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age or two first-degree relatives diagnosed at any age should be advised to start screening colonoscopy at 40 years of age or 10 years younger than the earliest diagnosis in their family, whichever comes first. In individuals with ulcerative colitis or Crohn disease with colonic involvement, colonoscopy should begin eight to 10 years after the onset of symptoms and be repeated every one to three years. Individuals who have a first-degree relative with hereditary nonpolyposis colorectal cancer should begin colonoscopy at 25 years of age and repeat colonoscopy every one to two years. In persons with a family history of adenomatous polyposis syndromes, screening should begin at 10 years of age or in a person's mid-20s, depending on the syndrome; repeat colonoscopy is typically required every one to two years. Screening colonoscopy should begin at eight years of age in individuals with Peutz-Jeghers syndrome. If results are normal, colonoscopy can be repeated at 18 years of age and then every three years. Persons with sessile serrated adenomatous polyposis should begin annual colonoscopy as soon as the diagnosis is established.

Probiotics for Gastrointestinal Conditions: A Summary of the Evidence

Probiotics contain microorganisms, most of which are bacteria similar to the beneficial bacteria that occur naturally in the human gut. Probiotics have been widely studied in a variety of gastrointestinal diseases. The most-studied species include Lactobacillus, Bifidobacterium, and Saccharomyces. However, a lack of clear guidelines on when to use probiotics and the most effective probiotic for different gastrointestinal conditions may be confusing for family physicians and their patients. Probiotics have an important role in the maintenance of immunologic equilibrium in the gastrointestinal tract through the direct interaction with immune cells. Probiotic effectiveness can be species-, dose-, and disease-specific, and the duration of therapy depends on the clinical indication. There is high-quality evidence that probiotics are effective for acute infectious diarrhea, antibiotic-associated diarrhea, Clostridium difficile- associated diarrhea, hepatic encephalopathy, ulcerative colitis, irritable bowel syndrome, functional gastrointestinal disorders, and necrotizing enterocolitis. Conversely, there is evidence that probiotics are not effective for acute pancreatitis and Crohn disease. Probiotics are safe for infants, children, adults, and older patients, but caution is advised in immunologically vulnerable populations.

Healthy lifestyle intervention for adult clinic patients with type 2 diabetes mellitus

BACKGROUND

Diet and exercise therapy have been reported to be effective in improving blood glucose control and are an important part of treatment of type 2 diabetes mellitus.

OBJECTIVE

The goal of this study is to examine the efficacy of a healthy lifestyle intervention for adult clinic patients with type 2 diabetes mellitus, as measured by Hgb-A1c, cardiovascular indicators, physical activity, weight, and BMI. Also of interest are optimal strategies for subject recruitment, the number of intervention sessions attended, and participant use of the Fitbit watch to monitor their physical activity and track food and beverage consumption.

METHODS

A pre/post-test design will be used in this pilot study. Non-institutionalized adult patients (n=50) aged 18-65 years who have been seen at the Augusta Health outpatient clinics (General Internal Medicine or Family Medicine) for type 2 diabetes in the past 12 months, and who are interested in reducing their risk of disease recurrence through healthy lifestyle behaviors, will be eligible to participate. At orientation visit, eligible individuals will be asked to provide written informed consent. Consenting volunteers (n=50) will be asked to complete the baseline and 6-month follow-up questionnaire and to participate in 12 weekly group sessions of 90 min duration, involving physical activity and to meet with a dietitian (baseline, one month, 90 days) to receive individualized advice on diet and nutrition. The technology-based intervention will use wrist-worn Fitbit Blaze physical activity monitoring devices.

CONCLUSIONS

This pilot study will provide important information about the feasibility and preliminary efficacy of a healthy lifestyle intervention for adult clinic patients with type 2 diabetes mellitus. The use of consumer-facing devices such as the Fitbit watch has the potential advantage over the use of research accelerometers, pedometers, or actigraphs in increasing the likelihood that the intervention will be sustainable after the study ends.

Gender and race disparities in weight gain among offenders prescribed antidepressant and antipsychotic medications

BACKGROUND

Studies have found that antipsychotics and antidepressants are associated with weight gain and obesity, particularly among women and some minority groups. Incarcerated populations (also referred to as offenders, prisoners or inmates) have a high prevalence of mental health problems and 15 % of offenders have been prescribed medications. Despite rates of antidepressant and antipsychotic use, investigations of weight gain and obesity in regard to these agents seldom have included offenders.

METHODS

This retrospective descriptive study (2005-2011) was conducted with a Department of Corrections in the east south central United States to investigate the relationship between antidepressant and antipsychotic agents, weight gain, obesity and race or gender differences. We sampled adult offenders who had an active record, at least two weight observations and height data. Offenders were classified into one of four mutually exclusive groups depending upon the type of medication they were prescribed: antidepressants, antipsychotics, other medications or no pharmacotherapy.

RESULTS

The sample population for this study was 2728, which was 25.2 % of the total population. The population not on pharmacotherapy had the lowest baseline obesity rate (31.7 %) compared to offenders prescribed antipsychotics (43.6 %), antidepressants (43.6 %) or other medications (45.1 %). Offenders who were prescribed antidepressants or antipsychotics gained weight that was significantly different from zero, p < .001 and p = .019, respectively. Women in the antidepressant group gained 6.4 kg compared to 2.0 kg for men, which was significant (p = .007). Although women in the antipsychotic group gained 8.8 kg compared to 1.6 kg for men, the finding was not significant (p = .122). Surprisingly, there were no significant differences in weight gain between African Americans and Whites in regard to antidepressants (p = .336) or antipsychotic agents (p = .335).

CONCLUSION

This study found that women and men offenders prescribed antidepressant or antipsychotic agents gained weight during their incarceration. Women prescribed antidepressants gained significantly more weight than men. However, there was no significant difference in weight gain between African Americans and Whites. Results suggest further investigation is needed to understand the effect of medication history, metabolic syndrome and to explain gender disparities.

Age, Race and Regional Disparities in Colorectal Cancer Incidence Rates in Georgia between 2000 and 2012

Colorectal cancer (CRC) incidence rates and mortality have been decreasing in the United States. Currently, states in the South have the smallest reduction in CRC mortality. The trends of CRC incidence rates in Georgia in comparison to the United States have not been investigated. We analyzed age-adjusted incidence rates of CRC in Georgia and the United States from 2000 to 2012 using data from SEER 18 registries. Age-adjusted incidence rates (95% CI) were calculated as cases per 100,000 to the 2000 US Standard population. CRC incidence rates were calculated for groupings based on age at time of diagnosis, race, sex, and geographic location within Georgia. Incidence rates were higher in males compared to females in Georgia. In Georgians age 50-64, incidence rates were higher compared to the US, while those ages 65+ displayed lower incidence rates. Black Georgians age 50-64 generally exhibited higher incidence rates of CRC and lower rates of decrease in incidence compared to other races in Georgia. Asian/Pacific Islander females age 50-64 in Georgia exhibited an increasing trend in incidence rate. Whites and blacks Georgians age 50-64 displayed higher incidence rates compared to the US, while Asian/Pacific Islanders displayed lower incidence rates. Greater incidence rates of CRC in rural and Greater Georgia were seen across all races when compared to overall rates in Georgia. Efforts should be made to address disparities in Georgia based on race and geographic location. Increased screening by colonoscopy or fecal occult blood testing, reduction of risk factors and promotion of healthy lifestyles can reduce CRC incidence rates.

Diagnosis and Management of Hepatitis C

Hepatitis C virus (HCV) infection, a major cause of chronic liver disease and cirrhosis, is predominantly transmitted by exposure to blood or body fluids. The infection progresses to a chronic state in 80% of patients, whereas the virus clears completely after the acute infection in 20% of patients. Screening for HCV with an anti-HCV antibody test is recommended for all adults at high risk of infection, and one-time screening is recommended in adults born between 1945 and 1965. If the anti-HCV antibody test result is positive, current infection should be confirmed with a qualitative HCV RNA test. In patients with confirmed HCV infection, quantitative HCV RNA testing and testing for HCV genotype is recommended. An assessment of the degree of liver fibrosis with liver biopsy or noninvasive testing is necessary to determine the urgency of treatment. Treatment of patients with chronic HCV infection should be considered based on genotype, extent of fibrosis or cirrhosis, prior treatment, comorbidities, and potential adverse effects. The goal of therapy is to reduce all-cause mortality and liver-associated complications. Although interferon-based regimens have been the mainstay of treatment for HCV infection, the U.S. Food and Drug Administration recently approved two combination-pill interferon-free treatments (ledipasvir plus sofosbuvir, and ombitasvir/paritaprevir/ritonavir plus dasabuvir) for chronic HCV genotype 1.

Colorectal cancer risk information presented by a nonphysician assistant does not increase screening rates

OBJECTIVE

To determine the effectiveness of presenting individualized colorectal cancer (CRC) risk information for increasing CRC screening rates in primary care patients at above-average risk of CRC.

DESIGN

Randomized controlled trial.

SETTING

Georgia Regents University in Augusta-an academic family medicine clinic in the southeastern United States.

PARTICIPANTS

Outpatients (50 to 70 years of age) scheduled for routine visits in the family medicine clinic who were determined to be at above-average risk of CRC.

INTERVENTIONS

Individualized CRC risk information calculated from the Your Disease Risk tool compared with a standard CRC screening handout.

MAIN OUTCOME MEASURES

Intention to complete CRC screening. Secondary measures included the proportions of subjects completing fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy.

RESULTS

A total of 1147 consecutive records were reviewed to determine eligibility. Overall, 210 (37.7%) of 557 eligible participants were randomized to receive either individualized CRC risk information (prepared by a research assistant) or a standard CRC screening handout. The intervention group had a mean (SD) age of 55.7 (4.8) years and the control group had a mean (SD) age of 55.6 (4.6) years. Two-thirds of the participants in each group were female. The intervention group and the control group were matched by race (P = .40). There was no significant difference between groups for intention to complete CRC screening (P = .58). Overall, 26.7% of the intervention participants and 27.7% of the control participants completed 1 or more CRC screening tests (P = .66).

CONCLUSION

Presentation of individualized CRC risk information by a nonphysician assistant as a decision aid did not result in higher CRC screening rates in primary care patients compared with presentation of general CRC screening information. Future research is needed to determine if physician presentation of CRC risk information would result in increased screening rates compared with research assistant presentation.

Fatigue, arthralgia, amenorrhea--Dx?

A 46-year-old Caucasian female with a history of epilepsy came into our family medicine center complaining of weakness, fatigue, and arthralgia that made it difficult for her to walk. She'd had these symptoms for 6 months and reported having amenorrhea and hot flashes for the past 2 years.

Nonalcoholic fatty liver disease: diagnosis and management

Nonalcoholic fatty liver disease is characterized by excessive fat accumulation in the liver (hepatic steatosis). Nonalcoholic steatohepatitis is characterized by steatosis, liver cell injury, and inflammation. The mechanism of nonalcoholic fatty liver disease is unknown but involves the development of insulin resistance, steatosis, inflammatory cytokines, and oxidative stress. Nonalcoholic fatty liver disease is associated with physical inactivity, obesity, and metabolic syndrome. Screening is not recommended in the general population. The diagnosis is usually made after an incidental discovery of unexplained elevation of liver enzyme levels or when steatosis is noted on imaging (e.g., ultrasonography). Patients are often asymptomatic and the physical examination is often unremarkable. No single laboratory test is diagnostic, but tests of liver function, tests for metabolic syndrome, and tests to exclude other causes of abnormal liver enzyme levels are routinely performed. Imaging studies, such as ultrasonography, computed tomography, and magnetic resonance imaging, can assess hepatic fat, measure liver and spleen size, and exclude other diseases. Liver biopsy remains the criterion standard for the diagnosis of nonalcoholic steatohepatitis. Noninvasive tests are available and may reduce the need for liver biopsy. A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance. There is insufficient evidence to support bariatric surgery, metformin, thiazolidinediones, bile acids, or antioxidant supplements for the treatment of nonalcoholic fatty liver disease. The long-term prognosis is not associated with an increased risk of all-cause mortality, cardiovascular disease, cancer, or liver disease.

Diagnosis and management of acute diverticulitis

Uncomplicated diverticulitis is localized diverticular inflammation, whereas complicated diverticulitis is diverticular inflammation associated with an abscess, phlegmon, fistula, obstruction, bleeding, or perforation. Patients with acute diverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever. Other symptoms may include anorexia, constipation, nausea, diarrhea, and dysuria. Initial laboratory studies include a complete blood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein. Computed tomography, the most commonly performed imaging test, is useful to establish the diagnosis and the extent and severity of disease, and to exclude complications in selected patients. Colonoscopy is recommended four to six weeks after resolution of symptoms for patients with complicated disease or for another indication, such as age-appropriate screening. In mild, uncomplicated diverticulitis, antibiotics do not accelerate recovery, or prevent complications or recurrences. Hospitalization should be considered if patients have signs of peritonitis or there is suspicion of complicated diverticulitis. Inpatient management includes intravenous fluid resuscitation and intravenous antibiotics. Patients with a localized abscess may be candidates for computed tomography-guided percutaneous drainage. Fifteen to 30 percent of patients admitted with acute diverticulitis require surgical intervention during that admission. Laparoscopic surgery results in a shorter length of stay, fewer complications, and lower in-hospital mortality compared with open colectomy. The decision to proceed to surgery in patients with recurrent diverticulitis should be individualized and based on patient preference, comorbidities, and lifestyle. Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, cessation of smoking, and, in persons with a body mass index of 30 kg per m(2) or higher, weight loss.

Aggression in a high secure hospital: staff and patient attitudes

Responding to aggressive behaviour is a key activity for nurses and other care staff in high secure hospitals. The attitudes and beliefs of staff regarding patient aggression will influence the management strategies they adopt. Patients will also hold attitudes regarding the causes of and best ways to respond to aggressive behaviour. This study measured the attitudes towards aggression of staff (n= 109) and patients (n= 27) in a high secure hospital in the UK using the Management of Aggression and Violence Attitude Scale (MAVAS). There was considerable concordance of views, staff and patients disagreeing on only two items on the MAVAS. Aggression was felt to have a range of causes, embracing factors internal to the person, factors in the external environment and situational or interactional factors. Interpersonal means of managing aggression were supported, but both staff and patients also advocated the use of controlling management strategies such as medication, seclusion and restraint. The implications of these findings for aggression management in high secure settings are discussed in the light of best practice guidelines that promote interpersonal approaches over controlling strategies.

Diagnosis and management of IBS in adults

Irritable bowel syndrome is defined as abdominal discomfort or pain associated with altered bowel habits for at least three days per month in the previous three months, with the absence of organic disease. In North America, the prevalence of irritable bowel syndrome is 5 to 10 percent with peak prevalence from 20 to 39 years of age. Abdominal pain is the most common symptom and often is described as a cramping sensation. The absence of abdominal pain essentially excludes irritable bowel syndrome. Other common symptoms include diarrhea, constipation, or alternating diarrhea and constipation. The goals of treatment are symptom relief and improved quality of life. Exercise, antibiotics, antispasmodics, peppermint oil, and probiotics appear to improve symptoms. Over-the-counter laxatives and antidiarrheals may improve stool frequency but not pain. Treatment with antidepressants and psychological therapies are also effective for improving symptoms compared with usual care. Lubiprostone is effective for the treatment of constipation-predominant irritable bowel syndrome, and alosetron (restrictions for use apply in the United States) and tegaserod (available only for emergency use in the United States) are approved for patients with severe symptoms in whom conventional therapy has been ineffective.

Diagnosis and management of upper gastrointestinal bleeding

Upper gastrointestinal bleeding causes significant morbidity and mortality in the United States, and has been associated with increasing nonsteroidal anti-inflammatory drug use and the high prevalence of Helicobacter pylori infection in patients with peptic ulcer bleeding. Rapid assessment and resuscitation should precede the diagnostic evaluation in unstable patients with severe bleeding. Risk stratification is based on clinical assessment and endoscopic findings. Early upper endoscopy (within 24 hours of presentation) is recommended in most patients because it confirms the diagnosis and allows for targeted endoscopic treatment, including epinephrine injection, thermocoagulation, application of clips, and banding. Endoscopic therapy results in reduced morbidity, hospital stays, risk of recurrent bleeding, and need for surgery. Although administration of proton pump inhibitors does not decrease mortality, risk of rebleeding, or need for surgery, it reduces stigmata of recent hemorrhage and the need for endoscopic therapy. Despite successful endoscopic therapy, rebleeding can occur in 10 to 20 percent of patients; a second attempt at endoscopic therapy is recommended in these patients. Arteriography with embolization or surgery may be needed if there is persistent and severe bleeding.

Diagnosis and management of Crohn's disease

Crohn's disease is a chronic inflammatory condition affecting the gastrointestinal tract at any point from the mouth to the rectum. Patients may experience diarrhea, abdominal pain, fever, weight loss, abdominal masses, and anemia. Extraintestinal manifestations of Crohn's disease include osteoporosis, inflammatory arthropathies, scleritis, nephrolithiasis, cholelithiasis, and erythema nodosum. Acute phase reactants, such as C-reactive protein level and erythrocyte sedimentation rate, are often increased with inflammation and may correlate with disease activity. Levels of vitamin B12, folate, albumin, prealbumin, and vitamin D can help assess nutritional status. Colonoscopy with ileoscopy, capsule endoscopy, computed tomography enterography, and small bowel follow-through are often used to diagnose Crohn's disease. Ultrasonography, computed axial tomography, scintigraphy, and magnetic resonance imaging can assess for extraintestinal manifestations or complications (e.g., abscess, perforation). Mesalamine products are often used for the medical management of mild to moderate colonic Crohn's disease. Antibiotics (e.g., metronidazole, fluoroquinolones) are often used for treatment. Patients with moderate to severe Crohn's disease are treated with corticosteroids, azathioprine, 6-mercaptopurine, or anti-tumor necrosis factor agents (e.g., infliximab, adalimumab). Severe disease may require emergent hospitalization and a multidisciplinary approach with a family physician, gastroenterologist, and surgeon.

Hepatitis C: diagnosis and treatment

Hepatitis C, a common chronic bloodborne infection, is found in approximately 2 percent of adults in the United States. Chronic infection is associated with serious morbidity and mortality (e.g., cirrhosis, hepatocellular carcinoma). Testing for hepatitis C is recommended for at-risk populations, and confirmatory testing includes quantification of virus by polymerase chain reaction. The U.S. Preventive Services Task Force recommends against routine screening for hepatitis C virus infection in asymptomatic adults who are not at increased risk of infection (general population). It found insufficient evidence to recommend for or against routine screening in adults at high risk of infection. Current therapy for chronic hepatitis C virus includes pegylated interferon and ribavirin. Therapy is based on factors that predict sustained virologic response, and the goal of therapy is to slow or halt progression of fibrosis and prevent the development of cirrhosis. In the future, multidrug regimens in combination with current therapies may be developed. Patients with chronic hepatitis C virus infection should be advised to abstain from alcohol use. Currently, there is no vaccine available to prevent hepatitis C virus infection; however, persons infected with hepatitis C virus should be vaccinated for hepatitis A and B. The American Association for the Study of Liver Diseases recommends ultrasound surveillance for hepatocellular carcinoma in persons with chronic hepatitis C virus infection and cirrhosis.

Hepatitis B: diagnosis and treatment

Although an estimated 1 million persons in the United States are chronically infected with hepatitis B virus, the prevalence of hepatitis B has declined since the implementation of a national vaccination program. Hepatitis B virus is transmitted in blood and secretions. Acute infection may cause nonspecific symptoms, such as fatigue, poor appetite, nausea, vomiting, abdominal pain, low-grade fever, jaundice, and dark urine; and clinical signs, such as hepatomegaly and splenomegaly. Fewer than 5 percent of adults acutely infected with hepatitis B virus progress to chronic infection. The diagnosis of hepatitis B virus infection requires the evaluation of the patient's blood for hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core antibody. The goals of treatment for chronic hepatitis B virus infection are to reduce inflammation of the liver and to prevent complications by suppressing viral replication. Treatment options include pegylated interferon alfa-2a administered subcutaneously or oral antiviral agents (nucleotide reverse transcriptase inhibitors). Persons with chronic hepatitis B virus infection should be monitored for disease activity with liver enzyme tests and hepatitis B virus DNA levels; considered for liver biopsy; and entered into a surveillance program for hepatocellular carcinoma.

Diverticular bleeding

Diverticular bleeding is a common cause of lower gastrointestinal hemorrhage. Patients typically present with massive and painless rectal hemorrhage. If bleeding is severe, initial resuscitative measures should include airway maintenance and oxygen supplementation, followed by measurement of hemoglobin and hematocrit levels, and blood typing and crossmatching. Patients may need intravenous fluid resuscitation with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells in the event of ongoing bleeding. Diverticular hemorrhage resolves spontaneously in approximately 80 percent of patients. If there is severe bleeding or significant comorbidities, patients should be admitted to the intensive care unit. The recommended initial diagnostic test is colonoscopy, performed within 12 to 48 hours of presentation and after a rapid bowel preparation with polyethylene glycol solutions. If the bleeding source is identified by colonoscopy, endoscopic therapeutic maneuvers can be performed. These may include injection with epinephrine or electrocautery therapy. If the bleeding source is not identified, radionuclide imaging (i.e., technetium-99m-tagged red blood cell scan) should be performed, usually followed by arteriography. For ongoing diverticular hemorrhage, other therapeutic modalities such as selective embolization, intra-arterial vasopressin infusion, or surgery, should be considered.

Screening colonoscopies by primary care physicians: a meta-analysis

PURPOSE

There is currently too few endoscopists to enact a national colorectal cancer screening program with colonoscopy. Primary care physicians could play an important role in filling this shortage by offering screening colonoscopy in their practice. The purpose of this study was to examine the safety and effectiveness of colonoscopies performed by primary care physicians.

METHODS

We identified relevant articles through searches of MEDLINE and EMBASE bibliographic databases to December 2007 and through manual searches of bibliographies of each citation. We found 590 articles, 12 of which met inclusion criteria. Two authors independently abstracted data on study and patient characteristics. Descriptive statistics were performed. For each outcome measure, a random effects model was used to determine estimated means and confidence intervals.

RESULTS

We analyzed 12 studies of colonoscopies performed by primary care physicians, which included 18,292 patients (mean age 59 years, 50.5% women). The mean estimated adenoma and adenocarcinoma detection rates were 28.9% (95% confidence interval [CI], 20.4%-39.3%) and 1.7% (95% CI, 0.9%-3.0%), respectively. The mean estimated reach-the-cecum rate was 89.2% (95% CI, 80.1%-94.4%). The major complication rate was 0.04% (95% CI, 0.01%-0.07%); no deaths were reported.

CONCLUSIONS

Colonoscopies performed by primary care physicians have quality, safety, and efficacy indicators that are comparable to those recommended by the American Society of Gastrointestinal Endoscopy, the American College of Gastroenterology, and the Society of American Gastrointestinal Endoscopic Surgeons. Based on these results, colonoscopy screening by primary care physicians appears to be safe and effective.

Colorectal cancer: a summary of the evidence for screening and prevention

Colorectal cancer causes significant morbidity and mortality in the United States. The incidence of colorectal cancer can be reduced with increasing efforts directed at mass screening of average-risk adults 50 years and older. Currently, fecal occult blood test and flexible sigmoidoscopy have the highest levels of evidence to support their use for colorectal cancer screening. Colonoscopy does not have a proven colorectal cancer mortality benefit, but it does have the greatest single-test accuracy, and it is the final test in the pathway to evaluate and treat patients with other abnormal screening tests. Double-contrast barium enema has sparse data of effectiveness. Computed tomographic colonography, fecal DNA testing, and Pillcam Colon are promising tests that need further study before they can be recommended for widespread screening. Routine screening should continue until 75 years of age. There is good evidence that fiber and antioxidants are not effective for primary prevention of colorectal cancer; they should not be recommended for chemoprevention. There is good evidence that aspirin, nonsteroidal antiinflammatory drugs, and cyclooxygenase-2 inhibitors are effective for decreasing the risk of colorectal cancer and adenomatous polyps, but increased risks, such as gastrointestinal bleeding, limit their usefulness. There is fair evidence that obesity is associated with colorectal cancer. Additional studies are needed on decreased fat intake and red meat consumption, and the use of calcium, vitamin D, and statins before these can be recommended for primary prevention of colorectal cancer.

Clostridial toxins active locally in the gastrointestinal tract

Clostridium difficile and Clostridium spiroforme have only in recent years been recognized as intestinal pathogens. They both produce toxins that are also produced by other clostridia. C. difficile toxins A and B are produced by C. sordellii and a few strains of C. perfringens whereas C. spiroforme produces the same toxins as C. perfringens Type E (iota toxin). Iota toxin activity may be the product of two proteins. Toxigenic strains of C. spiroforme and Type E produce two antigens which possess much more biological activity when administered together than when given alone. C. difficile was thought for some time to produce only a single toxin, but then the enterotoxic activity was shown to be due to a separate toxin (toxin A). This toxin increases the oral toxicity of toxin B (the main cytotoxin) and may increase the permeability of the colon. Toxin A binds to a specific receptor in hamster brush border membranes and in the membranes of rabbit erythrocytes. This receptor appears to be a glycoprotein. The receptor can be extracted from the membrane with Triton and binds to immobilized toxin A. The receptor can be extracted and used to coat plastic plates as a first phase in an ELISA assay. Another assay has been developed in which the toxin A binds to the red cells and then the erythrocytes are agglutinated with antitoxin. An even more sensitive assay consists of using rabbit erythrocyte ghosts to bind the toxin and then precipitating the ghosts with antibody to toxin A attached to latex beads. Monoclonal antibodies to toxin A also have been developed and are used in these and other assays.

Attitudes toward performance of endoscopic colon cancer screening by family physicians

BACKGROUND AND OBJECTIVES

This study's purpose was to examine attitudes of family physicians and gastroenterologists toward family physician performance of lower endoscopy in general practice.

METHODS

A mailed survey was sent to 1,563 board-certified physicians in Georgia (1,303 family physicians, 260 gastroenterologists). Respondents were asked to describe their practice of lower endoscopy procedures and colorectal (CRC) screening preferences.

RESULTS

Fifty-one percent (801) of the surveys were returned. For CRC screening, family physicians recommend fecal occult blood testing most frequently (51.7%), while gastroenterologists recommended colonoscopy most frequently (89.5%). Most family physicians believe that family physicians should perform flexible sigmoidoscopy (FS) (81.4%) and colonoscopy (CS) (71.3%). A total of 71.2% of surveyed gastroenterologists believe that family physicians should perform FS, but only a minority (4.5%) believe that family physicians should perform screening CSs. Approximately 28% (186) of family physicians report performing FS (mean=.8 FS per month). Only 3.7 % (25) of family physicians reported performing CS (mean=8.2 CSs per month).

CONCLUSIONS

Although most family physicians believe that they should perform lower endoscopy, only a minority of gastroenterologists believe family physicians should perform CS. Our results show that family physician performance of lower endoscopic CRC screening is limited in general practice. Future research might consider exploring these issues from both the gastroenterologist and family physician perspective.

The prevalence of dysphagia in primary care patients: a HamesNet Research Network study

PURPOSE

A number of disorders cause dysphagia, which is the perception of an obstruction during swallowing. The purpose of this study was to determine the prevalence of dysphagia in primary care patients.

METHODS

Adults 18 years old and older were the subjects of an anonymous survey that was collected in the clinic waiting room before patients were seen by a physician. Twelve family medicine offices in HamesNet, a research network in Georgia, participated.

RESULTS

Of the 947 study participants, 214 (22.6%) reported dysphagia occurring several times per month or more frequently. Those reporting dysphagia were more likely to be women (80.8% women vs 19.2% men, P = .002) and older (mean age of 48.1 in patients with dysphagia vs mean age of 45.7 in patients without dysphagia, P = .001). Sixty-four percent of patients with dysphagia indicated that they were concerned about their symptoms, but 46.3% had not spoken with their doctor about their symptoms. Logistic regression analyses showed that increased frequency [odds ratio (OR) = 2.15, 95% CI 1.41-3.30], duration (OR = 1.91, CI 1.24-2.94), and concern (OR = 2.64, CI 1.36-5.12) of swallowing problems as well as increased problems eating out (OR = 1.72, CI 1.19-2.49) were associated with increased odds of having talked to a physician.

CONCLUSIONS

This is the first report of the prevalence of dysphagia in an unselected adult primary care population. Dysphagia occurs commonly in primary care patients but often is not discussed with a physician.

The current state of flexible sigmoidoscopy training in family medicine residency programs

BACKGROUND AND OBJECTIVES

The US Preventive Services Task Force has recommended that adults ages 50 and over be screened for colorectal cancer. Flexible sigmoidoscopy (FS) is one available screening option. This study determined the current state of FS training in US family medicine residencies.

METHODS

Directors of the Accreditation Council for Graduate Medical Education-accredited family medicine residencies were surveyed regarding FS training.

RESULTS

Of 486 mailed surveys, 370 (76%) were completed and returned. Fifty-two percent of responding residency programs trained at least one resident in FS in 2003. Residents in these programs performed a mean of 20.1 +/- 1.2 FSs during their training. In 2003, 44% of family medicine graduates from these programs were certified by their programs as competent to perform FS. Fewer residents were certified in FS by programs in the eastern versus western United States. Military programs certified more residents than did nonmilitary programs.

CONCLUSIONS

More than half of programs offered FS training, but less than half of family medicine graduates were certified by their programs as competent. There were significant differences for FS training by region and program type.

EMBASE versus MEDLINE for family medicine searches: can MEDLINE searches find the forest or a tree?

OBJECTIVE

Many physicians access electronic databases to obtain up-to-date and reliable medical information. In North America, physicians typically use MEDLINE as their sole electronic database whereas in Europe, physicians typically use EMBASE. While MEDLINE and EMBASE are similar, their coverage of the published literature differs. Searching a single literature database (eg, MEDLINE or EMBASE) has been shown not to yield all available citations, and using two or more databases yields a greater percentage of these available citations. This difference has been demonstrated in a variety of disciplines and in family medicine using the term "family medicine," but differences have not been shown using specific diagnostic terms common in family medicine. We sought to determine whether searching EMBASE with terms for common family medicine diagnoses yields additional references beyond those found by using MEDLINE alone.

DESIGN

Literature search comparison.

SETTING

An academic medical centre in the United States.

INTERVENTIONS

Fifteen family medicine topics were selected based on common diagnoses in US primary care health visits as described in a National Health Care Survey on Ambulatory Care Visits. To promote relevance to family medicine physicians and researchers, the qualifiers "family medicine" and "therapy/therapeutics" were added. These topics were searched in EMBASE and MEDLINE. Searches were executed using Ovid search engine and were limited to the years 1992 to 2003, the English language, and human subjects. Total, duplicated, and unique (ie, nonduplicated) citations were recorded for each search in each database.

MAIN OUTCOME MEASURES

Number of citations for the 15 topics.

RESULTS

EMBASE yielded 2246 (65%) of 3445 total citations, whereas MEDLINE yielded 1199 citations. Of the total citations, only 177 articles were cited in both databases. EMBASE had 2092 unique citations to MEDLINE's 999 unique citations. EMBASE consistently found more unique citations in 14 of the 15 searches (P = .0005).

CONCLUSION

Overall, EMBASE provides twice as many citations per search as MEDLINE and provides greater coverage of total retrieved citations. More citations do not necessarily mean higher-quality citations. In a comprehensive search specific to family medicine, combined EMBASE and MEDLINE searches could yield more articles than MEDLINE could alone.

Office-based ultrathin esophagogastroduodenoscopy in a primary care setting

BACKGROUND

Upper gastrointestinal complaints are common in primary care. These patients are often referred for evaluation with the use of esophagogastroduodenoscopy. This study examines the feasibility and safety of office-based ultrathin (diameter, 5.9 mm) esophagogastroduodenoscopy (u-EGD) without conscious sedation in a primary care setting.

METHODS

This study is a retrospective chart review in a university-based family medicine residency in the southeastern United States. Charts were reviewed for adult outpatients (N = 126) who were referred for further evaluation of heartburn, dyspepsia, or epigastric pain and who elected to undergo u-EGD procedure. We examined the number of patients willing to undergo office-based u-EGD, patient demographics, procedure indications and findings, patient request for oral benzodiazepines, and procedure and recovery times.

RESULTS

Of the 132 patients asked to participate in office-based u-EGD, 126 (95.4%) were willing to undergo this procedure (mean age, 47.6 +/- 1.3; 75% women). Of 126 patients, 122 (96.8%) tolerated office-based u-EGD, and 80.6% of patients requested oral anxiolytic medications. Significantly more women than men requested oral anxiolytic medications (84.0% versus 65.6%, respectively; P = .026). The retroflexion maneuver was completed in 120 of 122 (98.4%) patients, and the second portion of duodenum was reached in 122 of 122 (100%) patients. Mean procedure time was 16.9 +/- 0.7 minutes, and mean recovery time was 3.8 +/- 0.2 minutes. There were no complications reported in this case series.

CONCLUSIONS

The majority of patients can tolerate office-based u-EGD without conscious sedation in a primary care setting, but most patients request oral anxiolytic medications. Statistically more women request oral anxiolytic medications than do men.

Office-based unsedated ultrathin esophagoscopy in a primary care setting

PURPOSE

Gastroesophageal reflux disease is common and with time may be complicated by Barrett's esophagus and esophageal adenocarcinoma. Upper gastrointestinal endoscopy, including esophagoscopy, is the procedure of choice to diagnose Barrett's esophagus and other esophageal disease. The use of unsedated ultrathin esophagoscopy (UUE) has been reported by gastroenterologists in specialized endoscopy units and otolaryngologists in outpatient otolaryngology offices, but UUE has not been previously described in a primary care setting. This study examines the feasibility of office-based UUE in primary care.

METHODS

This study is a retrospective chart review in a university-based family medicine clinic in the southeastern United States. Charts were reviewed of 56 adult outpatients who were referred for further evaluation of reflux symptoms that persisted after at least 4 weeks of therapy with histamine(2) receptor agonists or proton pump inhibitors and who elected to undergo UUE in the primary care setting. Patient demographics, procedure indications and findings, changes in clinical management, and procedure times were recorded.

RESULTS

One hundred percent of patients asked to participate in UUE were willing to undergo the procedure (mean age 48.3 +/- 1.6 y, 57.1% women); 95% of the patients tolerated UUE. Barrett's esophagus was diagnosed in 5.7% (n = 3) of the patients. Mean procedure time was 5.5 +/- 1.7 min. No complications were reported in this series.

CONCLUSIONS

Initial data suggest that UUE is feasible in primary care, with the majority of patients tolerating the procedure. UUE may be an efficient method of examining the distal esophagus.

The current state of colonoscopy training in family medicine residency programs

BACKGROUND AND OBJECTIVES

The US Preventive Services Task Force has recommended that all adults ages 50 and over be screened for colorectal cancer. Colonoscopy is the most accurate screening procedure, but the feasibility of colonoscopy as a screening tool is limited by the number of physicians trained to perform it. This study determined the current state of colonoscopy training in US family medicine residency programs.

METHODS

We surveyed program directors of all Accreditation Council for Graduate Medical Education-approved family medicine residency programs regarding colonoscopy training.

RESULTS

The response rate was 94% (426 of 455). Forty-eight percent (n=201) of directors reported that their program offered colonoscopy training, but only 18% (n=75) of all respondents had actually trained one or more residents to do colonoscopies. Nationally, the mean number of colonoscopies performed per resident was 42.6 +/- 3.9. Regional differences were reported; residents trained in the western United States performed a mean of 69.8 +/- 12.8 colonoscopies per resident. Gastroenterologists in hospital-based gastroenterology suites trained approximately 75% of family medicine residents. Fifteen percent (n=64) of directors reported that 133 (4%) of their July 2002 graduates sought credentials to perform colonoscopy.

CONCLUSIONS

Only a minority of family medicine graduates seek credentials to perform colonoscopy, and significant regional differences in training exist.

The current state of esophagogastroduodenoscopy training in family practice residency programs

BACKGROUND AND OBJECTIVES

Esophagogastroduodenoscopy (EGD) is a useful diagnostic procedure to evaluate patients with upper gastrointestinal complaints. Although family physicians have demonstrated that they can competently perform EGD, only a minority of family physicians perform EGD. This study determined the current state of EGD training in US family practice residency programs and how often graduating residents seek EGD privileges.

METHODS

We conducted a cross-sectional descriptive study surveying program directors from all Accreditation Council for Graduate Medical Education-approved family practice residency programs regarding EGD training in their program.

RESULTS

Of the 471 surveys mailed, 441 (94%) were returned. A total of 143 (32%) program directors reported that their program offered EGD training, but only 58 (13%) actually trained at least one resident. Residents performed a mean of 20 +/- 2.4 EGDs per resident, and residents trained by family physicians performed more EGDs than residents trained by other specialties. In July 2000, .04% of graduating family practice residents sought credentials for EGD, and their training occurred in 32 (7%) residency programs.

CONCLUSIONS

Only a minority of family practice residents seek credentialing after residency to perform EGD.

Comparison of thin versus standard esophagogastroduodenoscopy

OBJECTIVE

To compare the tolerance, feasibility, and safety of ultrathin esophagogastroduodenoscopy (EGD) in unsedated patients with conventional EGD in sedated patients.

STUDY DESIGN

This was an unblinded, randomized controlled trial.

POPULATION

Diagnostic EGD was performed on 72 adult outpatients at a US Air Force community hospital residency. Patients were randomized to either ultrathin or conventional EGD (n = 33 and 39, respectively).

OUTCOMES MEASURED

Patients reported their tolerance of the procedure (pain, choking, gagging, and anxiety; scale 0-10), and the endoscopist reported the effectiveness of the procedure (successful intubation, reaching duodenum, retroflexion, and duration of examination and recovery) and safety (complications).

RESULTS

No statistically significant difference was noted between the 2 groups in mean procedure time or pain during the procedure. Mean ( standard error) recovery time was approximately halved in the ultrathin group vs the conventional group (21.5 +/- 2.3 min vs 55.4 +/- 2.3 min, P < 0001). Although patients undergoing ultrathin EGD had higher mean gagging and choking scores, they had lower mean anxiety scores. Of 33 patients randomized to the unsedated ultrathin EGD procedure, 29 completed the protocol. The retroflexion maneuver was completed in 85% of patients in the ultrathin EGD group and 100% of patients in the conventional EGD group (P =.017). No statistically significant difference was noted between groups as to the likelihood of reaching the second portion of the duodenum (97% vs 100%).

CONCLUSIONS

Most patients tolerate ultrathin EGD with significantly shorter recovery time and less overall anxiety than with the conventional procedure. Techniques to reduce gagging and choking associated with ultrathin EGD may improve patient acceptance and tolerability. Adoption of ultrathin EGD by primary care physicians may decrease cost, time, and inconvenience while increasing access to EGD for many patients.

The Arabidopsis det3 mutant reveals a central role for the vacuolar H(+)-ATPase in plant growth and development

In all multicellular organisms growth and morphogenesis must be coordinated, but for higher plants, this is of particular importance because the timing of organogenesis is not fixed but occurs in response to environmental constraints. One particularly dramatic developmental juncture is the response of dicotyledonous seedlings to light. The det3 mutant of Arabidopsis develops morphologically as a light-grown plant even when it is grown in the dark. In addition, it shows organ-specific defects in cell elongation and has a reduced response to brassinosteroids (BRs). We have isolated the DET3 gene by positional cloning and provide functional and biochemical evidence that it encodes subunit C of the vacuolar H(+)-ATPase (V-ATPase). We show that the hypocotyl elongation defect in the det3 mutant is conditional and provide evidence that this is due to an alternative mechanism of V-ATPase assembly. Together with the expression pattern of the DET3 gene revealed by GFP fluorescence, our data provide in vivo evidence for a role for the V-ATPase in the control of cell elongation and in the regulation of meristem activity.

Trophoblast deportation in human pregnancy--its relevance for pre-eclampsia

The maternal syndrome of pre-eclampsia is thought to result from endothelial cell damage caused by a circulating factor derived from the placenta. This study investigates the hypothesis that trophoblast deportation may be part of the process by which this factor enters the maternal circulation. The nature and incidence of trophoblast deportation was studied in uterine vein and peripheral blood taken from normal and pre-eclamptic women at caesarean section. Trophoblasts were enriched using immunomagnetic beads to deplete leucocytes and labelled with trophoblast-specific monoclonal antibodies. Syncytiotrophoblast, cytotrophoblast, cytotrophoblast clumps and anucleate trophoblast cells were found in uterine vein blood. Cytotrophoblast cells were found to be shed less frequently than syncytiotrophoblast and the majority were probably villous in origin. Trophoblasts were found in the uterine vein blood of normal pregnant women with higher levels in pre-eclampsia. However, trophoblasts were rarely found in the peripheral circulation. There was no correlation between trophoblast numbers and either the severity of the disease, the extent of placental pathology or the inhibitory effect of uterine and peripheral vein plasma on endothelial growth in vitro. Thus, it is speculated that increased trophoblast deportation in pre-eclampsia is secondary to the structural and functional changes occurring in the placenta, rather than directly linked with the circulating endothelial cell damaging factor in pre-eclampsia.

Maternal peripheral blood leukocytes in normal and pre-eclamptic pregnancies

OBJECTIVE

To analyse activation of maternal peripheral blood leukocytes by flow cytometric measurements of intracellular free-ionised calcium of lymphocytes, granulocytes and monocytes, separately.

DESIGN

Case-control study.

SETTING

High risk pregnancy service in a regional centre.

MATERIAL

Samples from 10 women with pre-eclampsia, 10 appropriately-matched women with normal pregnancy, nine multigravid normal women at mid-gestation selected as being least likely to demonstrate any tendencies towards pre-eclampsia, and 11 healthy nonpregnant women of reproductive age were studied.

METHODS

Using flow cytometry, intracellular free ionised calcium ([Ca2+]i) was estimated by loading the cells with Fluo-3 and measuring the changes in fluorescence intensity induced by free ionised calcium. After the basal levels were measured, the response of phagocytes to stimulation with n-formylmethionyl-leucyl-phenylalanine (fMLP) was determined.

MAIN OUTCOME MEASURES

Basal [Ca2+]i of peripheral blood leukocytes.

RESULTS

Median basal [Ca2+]i was significantly increased in all three subsets of leukocytes--lymphocytes, granulocytes and monocytes in pre-eclampsia--compared with the three control groups. Samples from both groups of women with normal pregnancy did not differ from those from nonpregnant women. The peak responses of monocytes to stimulation with 10 nmol fMLP were greater in samples from pre-eclamptic women, giving evidence of priming.

CONCLUSIONS

Peripheral blood leukocytes are activated in pre-eclampsia in terms of basal changes in the intracellular second messenger--free ionised calcium. Peripheral blood monocytes are primed to give greater responses after stimulation with fMLP.

Diagnosis of pathogenic Entamoeba histolytica infection using a stool ELISA based on monoclonal antibodies to the galactose-specific adhesin

Monoclonal antibodies (MAbs) directed against pathogen-specific epitopes of the galactose adhesin of Entamoeba histolytica were used in an ELISA to detect antigen from pathogenic E. histolytica. Single stool specimens from 74 patients in Bangladesh were used. The ELISA for pathogenic E. histolytica was positive in all 12 stool specimens with pathogenic amebae subsequently cultured, in no stool specimens with nonpathogenic E. histolytica and in 2 of 40 stools with other or no intestinal parasites detected. Specificity and sensitivity of the assay for pathogenic E. histolytica were 97% and 100%, respectively. These preliminary data offer promise for an ELISA using MAbs to the galactose adhesin as a rapid and sensitive means to detect the presence of pathogenic E. histolytica infection in stool specimens.

Localization of tumour necrosis factor production in cells at the materno/fetal interface in human pregnancy

Biologically active tumour necrosis factor (TNF) was detected in medium conditioned by incubation with explants of human pregnancy decidua or fetal chorionic villous tissue, taken in the first trimester and at term. Addition of endotoxin increased TNF release in most cases. ELISA assays gave similar results for TNF-alpha and also demonstrated low levels of TNF-beta. Using cell populations purified by flow cytometry, secretion of biologically active TNF was shown to be localized to the macrophages. Cytotrophoblast purified from term amniochorion produced no TNF. Both decidual and chorionic villous tissue at term contained mRNA for TNF-alpha and TNF-beta. TNF-alpha mRNA was confined to decidual macrophages in first trimester tissue, and was not present in chorionic cytotrophoblast. TNF-beta mRNA, in contrast, was detected in both macrophage and non-macrophage populations in term decidua.

Trophoblast deportation in pre-eclamptic pregnancy

OBJECTIVES

To examine the deportation of trophoblast cells into the maternal blood in pre-eclamptic (gestational proteinuric hypertension) and normal pregnancy.

DESIGN

The monoclonal anti-cytokeratin antibody JMB2 was used in the APAAP technique to label trophoblast cells in cell smears of uterine vein blood obtained at caesarean section.

SUBJECTS

10 women with proteinuric pre-eclampsia requiring caesarean section, 10 pregnant women requiring elective caesarean section for reasons other than pre-eclampsia and five control women who had never been pregnant.

RESULTS

Three populations of trophoblast cells were identified; two mononuclear cytotrophoblast types with diameters varying from 11-14 microns and 19-25 microns respectively, and multinucleated syncytiotrophoblast cells varying in size from 23-88 microns. Women with pre-eclampsia had more trophoblast cells in uterine vein blood than were found in pregnant women without pre-eclampsia. There was no correlation between the numbers of trophoblast cells and the stage of gestation or severity of the pre-eclampsia, although an acute maternal or fetal event necessitating delivery was associated with increased deportation of trophoblast. Mononuclear cytotrophoblast cells were detected in the peripheral blood of only 1 of 5 pre-eclamptic patients, despite their presence in the uterine vein blood of all 5 women.

CONCLUSIONS

Trophoblast deportation is increased in pre-eclamptic pregnancy, with both cytotrophoblast and syncytiotrophoblast present in the uterine vein blood, but there is no correlation with the severity of the disease. In some cases cytotrophoblast may also enter the peripheral circulation.