Utility of upper endoscopy in the evaluation of noncardiac chest pain

The diagnostic yield of esophagogastroduodenoscopy, esophageal manometry, and Bernstein testing was assessed in 100 consecutive patients being evaluated for non-cardiac chest pain. Manometric studies revealed the nutcracker esophagus in 21 patients; non-specific esophageal motility disorders in 19 patients; a hypertensive lower esophageal sphincter in 4 patients; diffuse esophageal spasm in 2 patients; and normal motility in 54 patients. Endoscopy was normal in 38 patients; but revealed grades II to IV esophagitis in 24 patients; gastritis and/or duodenitis in 18 patients; a sliding hiatal hernia without evidence of esophagitis in 14 patients; and gastric or duodenal ulcers in 6 patients. Twenty-five individuals were found to have normal manometric studies in combination with a negative Bernstein test. Among these 25 patients, however, 7 patients had esophagitis (grade II or higher); 6 patients had gastritis and/or duodenitis; five patients had a sliding hiatal hernia without esophagitis; 1 patient had peptic ulcer disease; and only 6 patients had a normal endoscopic exam. Our results indicate that endoscopy can identify a significant number of patients with acid-peptic disease who present with non-cardiac chest pain, that would not have been otherwise diagnosed by esophageal manometry or Bernstein testing alone or in combination.     

Evaluation of sulphasalazine in the treatment of spondyloarthropathies.

Sulphasalazine has been shown to have an effect in patients with spondyloarthropathies, but the clinical indication for its use is controversial and its long term effect has not yet been evaluated. Treatment with sulphasalazine was analysed retrospectively in a group of 372 patients with a wide range of spondyloarthropathies to determine subsets of patients showing differential effects of the drug. One hundred and one patients received sulphasalazine at a mean daily dose of 2 g (ankylosing spondylitis, 54 patients; psoriatic arthritis, 21 patients; reactive arthritis, four patients; arthritis related to inflammatory bowel disease, six patients; undifferentiated spondyloarthropathy, 16 patients). A comparison between treated and untreated patients suggests that only patients with active and severe disease were treated whatever the precise diagnosis or the amount of axial disease in the spondyloarthropathy. After six months of treatment improvement was noted in 59 patients unrelated to their subgroup or amount of axial disease. After a mean follow up of 20 months, 37 patients were still receiving treatment, 33 had discontinued the drug because of inefficacy, 14 because of side effects, six because of remission of the disease, and 11 for other reasons. Comparison between the beginning and end of treatment showed a statistically significant decrease in morning stiffness, erythrocyte sedimentation rate, and daily dose of non-steroidal anti-inflammatory drugs (NSAIDs). It is concluded that: (a) a low percentage of patients with spondyloarthropathy have active disease requiring treatment with sulphasalazine despite the use of NSAIDs (27% in this study); (b) in this subgroup of patients sulphasalazine seems to be of clinically relevant benefit in 59%; and (c) this benefit does not seem to be correlated with either the precise diagnosis of spondyloarthropathy or the amount of axial disease.     

Internal medicine treatment of pleural empyema

We made a retrospective analysis with regard to the bacteriology and to the therapy of all patients with pleural empyema who were treated in the district lung hospital from 1. 1. 1982-31. 12. 1986. 92 patients had a non-specific empyema, only 3 patients had a specific empyema. All patients were aspirated repeatedly with physiological saline solution instillation and antimicrobic drug instillation in the pleural cavity. This daily aspiration and lavage was successfully in 65 patients. This method was ineffective in 30 patients. We treated 7 patients of this group by the closed drainage (rubber-tube drain), in 4 patients successfully. 3 patients had to be treated by a surgical operation. An insufficient obliteration of the cavity of empyema occurred also in 23 patients of this group. A systematic daily aspiration for a longer time led to regression of the cavity in 4 cases, whereas a surgical operation was necessary in 19 patients. We consider the daily aspiration and lavage as an effective method in patients in early acute stages of empyema.     

The role of azathioprine in the management of ulcerative colitis

The use of azathioprine in ulcerative colitis is unclear. The authors present the details and outcome of 47 patients who received azathioprine for either a) severe, resistant disease otherwise requiring surgery (28 patients) or b) patients with steroid dependence who have been followed up for at least 12 months (19 patients). Duration of treatment ranged from one week to 66 months (median, 12 months). Of the patients in Group I, 13 (46 percent) achieved remission, 11 of whom had not relapsed during a median follow-up of 22 months (range, 12 to 58 months), and 15 underwent surgery one week to 12 months (median, five weeks) after commencing azathioprine. In Group II, steroids were withdrawn or reduced in 12 (63 percent) patients and three patients required colectomy. Side effects necessitating withdrawal of azathioprine occurred in 12 patients (hematologic effects, 6 patients; gastrointestinal effects, 4 patients; other effects, 2 patients). Two patients required a reduced dose of azathioprine because of leukopenia. The authors conclude that azathioprine is a valuable therapeutic option in selected patients with ulcerative colitis.     

Treatment of patients over 50 years of age with acute myelogenous leukemia with a combination of rubidazone and cytosine arabinoside, vincristine, and prednisone (ROAP)

We administered a combination of rubidazone, cytosine arabinoside, vincristine, and prednisone (ROAP) to 91 patients with acute myelogenous leukemia who were 50 yr of age or older. These patients had been identified in previous studies to be a group with a relatively poor prognosis. One-third of the patients had an antecedent hematologic disorder prior to treatment. Forty patients (48%) obtained a complete hematologic and clinical remission. A history of an antecedent hematologic disorder, male sex, and absence of Auer rods were adverse factors for achieving remission in this older population. More than half of the patients achieved remission in one course. The major cause of failure to obtain a remission was death due to infection, 40% of which were caused by fungi. Resistance to chemotherapy, although uncommon, was noted more frequently in patients with an antecedent hematologic disorder. Univariate and multivariate prognostic factor analysis was used to compare these patients with a historical control group treated with a program in which adriamycin was used instead of rubidazone (AdOAP). No significant difference in remission rate was detected. Cyclocytidine was used as a maintenance agent in this study, and while the median remission duration was only 37 wk, 30% of patients are expected to be in remission for 2 yr. Chemotherapy programs combining an anthracycline with cytosine arabinoside, given to older patients in similar fasion to younger patients will achieve remissions in one-half of a group of older patients. These remissions are of comparable quality to those of younger patients. Mathematical models derived from analysis of prognostic factors are of use in identifying patients likely to fail these programs who are in need of innovative approaches to treatment.     

The value of prospective monitoring of Epstein–Barr virus DNA in blood samples of pediatric liver transplant recipients

Post-transplant lymphoproliferative disease (PTLD) is one of the major causes of morbidity and mortality in transplantation patients. A primary Epstein-Barr virus (EBV) infection is a major risk factor for developing PTLD. The aim of this study was to determine circulating EBV DNA after liver transplantation in pediatric patients in relation to primary EBV infection and development of PTLD. EBV serology was performed before transplantation. Every 4 weeks after transplantation a competitive quantitative polymerase chain reaction (PCR) assay for EBV nuclear antigen-1 was performed in 13 patients. Patients were followed for development of a PTLD. Before transplantation four patients were EBV seropositive and nine patients were EBV seronegative. In one of the four patients who were EBV seropositive before transplantation, EBV DNA became detectable after transplantation, with a peak load of 3600 copies/mL. None of these four patients developed a PTLD. Eight of the nine patients who were EBV seronegative before transplantation developed positive EBV DNA samples. EBV DNA was first detected at a mean of 64 days after transplantation (range 38-89). The mean peak EBV DNA load was 79,700 copies/mL (3600-446,000). Two of these patients developed PTLD, but they could not be identified based on prior or concomitant EBV PCR results. Conclusions: In pediatric liver transplantation EBV DNA load is higher in patients with a primary infection than in patients who were EBV seropositive before transplantation. The EBV PCR cannot be used to identify individual patients who develop PTLD. However, elevated EBV DNA load can be used to detect a group of patients at increased risk for PTLD.     

Gastric cancer patients at high-risk of having synchronous cancer

AIM: To identify patients with a high-risk of having a synchronous cancer among gastric cancer patients. METHODS: We retrospectively analyzed the prospective gastric cancer database at the National Cancer Center, Korea from December 2000 to December 2004. The clinicopathological characteristics of patients with synchronous cancers and those of patients without synchronous cancers were compared. Multivariate analysis was performed to identify the risk factors for the presence of a synchronous cancer in gastric cancer patients. RESULTS: 111 of 3291 gastric cancer patients (3.4%) registered in the database had a synchronous cancer. Among these 111 patients, 109 had a single synchronous cancer and 2 patients had two synchronous cancers. The most common form of synchronous cancer was colorectal cancer (42 patients, 37.2%) followed by lung cancer (21 patients, 18.6%). Multivariate analyses revealed that elderly patients with differentiated early gastric cancer have a higher probability of a synchronous cancer. CONCLUSION: Synchronous cancers in gastric cancer patients are not infrequent. The physicians should try to find synchronous cancers in gastric cancer patients, especially in the elderly with a differentiated early gastric cancer.     

A further exploration of the use of physical restraints in hospitalized patients

Four hundred twenty-one consecutive patients admitted to an acute general medical ward and two acute rehabilitation medical wards were studied to compare the characteristics and outcomes of physically restrained patients and unrestrained patients. Restraints were used in 35 (13%) of the general medical patients and in 49 (34%) of the rehabilitation patients. The restrained general medical patients had higher mortality and morbidity rates than their unrestrained counterparts. Restrained patients had a higher prevalence of a psychiatric diagnosis, and major tranquilizers were used more than in their unrestrained counterparts in both settings. The general medical patients tended to have more than one type of restraint at a time, whereas the rehabilitation patients were restrained for longer proportions of their hospital stay. Thirty-three percent of the restrained patients whom we were able to interview expressed negative perceptions about the presence of the physical restraints. Moreover, it was found that the presence of cognitive and physical impairments were highly predictive of restraint use in both populations.     

Detection of unsuspected cases of nosocomial transmission of tuberculosis by use of a molecular typing method.

The aim of this study was to use restriction fragment length polymorphism to detect unsuspected cases of nosocomial transmission of tuberculosis (TB) among patients who had been admitted to a university hospital. One hundred fifty-one samples of Mycobacterium tuberculosis isolated from patients with pulmonary TB were studied. The isolates from 37 patients (24.5%) defined 11 clusters. None of the patients infected with these cluster isolates had hospital stays that coincided with one another, and for 5.4% of the patients, the epidemiological link was clearly outside the hospital. Previous incarceration was associated with infection with cluster isolates. In addition, 109 patients without TB (41 of whom were infected with human immunodeficiency virus) who shared a room with patients who had TB were followed for 18-60 months. Among the patients who survived, secondary cases of TB due to nosocomial transmission were not detected.     

Nutritional status and quality of life of the gastric cancer patients in Changle County of China

AIM: To analyze the relation between nutrition and quality of life in the stomach cancer patients, evaluate the intake of daily nutrition of the patients, and study the feasibility of nutrition intervention in improving quality of life of the stomach cancer patients. METHODS: A total of 285 surgical stomach cancer patients reported in the Changle Cancer Registry from 2002 to 2003 were investigated with respect to their diet and quality of life. Daily nutrition intakes of the patients were calculated according to the Food Composition Database, and these data were compared with the reference values proposed by the Chinese Nutrition Society. The partial correlation was used to analyze the relationship between nutrition and quality of life in the patients. Stepwise multiple regression analyses were conducted to analyze the factors influencing nutrition intake in stomach cancer patients. RESULTS: Except vitamin C, there were statistical correlations between the nutrition and quality of life in stomach cancer patients, and differences of the daily nutrition intake among three groups (good, modest and bad quality of life) of the patients were significant. Most of the stomach cancer patients had a lower daily nutrition intake than the reference values. At the significance level α=0.05, the factors influencing the daily nutrition intake of the patients were number of meals a day, family income, way of operation, exercise and age. CONCLUSION: The nutritional status of the operated patients with stomach cancer may impact on their quality of life. The stomach cancer patients in Changle County have a low level of daily nutrition intake, which suggests that they have a bad nutritional status. To improve the quality of life of the patients, the nutrition intervention should be conducted. Increasing times of meals a day and having a high-protein, high-calorie foods can improve the nutritional status of the stomach cancer patients. Moreover, exercise for rehabilitation can whet the appetite of the patients and recover their body function, which in turn may improve the quality of life of the stomach cancer patients.     

Yield of the screening review of systems

STUDY OBJECTIVE: To determine the usefulness of screening reviews of the cardiopulmonary and gastrointestinal systems during medical admissions. DESIGN: Case series. SETTING: General internal medicine ward of a university hospital. PATIENTS: 550 consecutive medical patients were initially screened at admission. The authors excluded 265 patients with life-limiting medical conditions, and they studied 98 patients with no known cardiopulmonary disease and 207 patients with no known gastrointestinal disease. INTERVENTIONS: Positive responses to screening systems review questions were evaluated using a standardized testing algorithm. MAIN OUTCOME MEASURES: Numbers of new diagnoses; potential for patient benefit. MAIN RESULTS: The authors made 26 new diagnoses for 25 patients (95% confidence limits, 16 to 37 patients), two of whom may have gained years of life as a result. CONCLUSIONS: The absolute yield of the screening cardiopulmonary and gastrointestinal reviews of systems of 550 patients admitted to an internal medicine service of a university hospital was a new diagnosis in about 5% of patients. An estimate of the cost-effectiveness compares favorably with those of other accepted screening practices.     

Long-term results of transluminal coronary angioplasty of chronic coronary artery occlusions

In 43 patients an occlusion of the coronary artery, which had occurred a few weeks or months previously, was diagnosed between 1977 and 1983. Angiograms were available prior to the occlusion in 35 patients but not in 8 patients. In 31 patients mechanical revascularization was attempted with acute success in 42 percent of the patients. The primary success rate in a control population without occlusion but high-grade stenoses at similar sites was 83 percent. Reocclusions or high-grade restenoses occurred in 54 percent of the revascularized vessels. Taking into account successful repeated dilatations, 62 percent of the successfully treated patients showed long-term success a year after intervention. With reference to all patients in whom revascularization had been attempted, the long-term success rate was 26 percent. Hence, mechanical revascularization of subacute and chronic artery occlusions by angioplasty shows much less chance of acute success together with a markedly increased restenosis rate compared to angioplasty of chronic stenoses. Regarding the good long-term results in a quarter of patients, the technically unproblematic approach as well as minimal dangers for the patients, a revascularization attempt seems to be justified in corresponding clinical presentations.     

Use of preoperative ultrasound staging for treatment of rectal cancer

INTRODUCTION: Transrectal ultrasound is the standard method for preoperative staging of rectal cancer. This study reviews the accuracy of transrectal ultrasound staging for T3 disease and its use in the selection of patients for neoadjuvant chemoradiation. METHODS: One hundred seventeen patients underwent preoperative transrectal ultrasound evaluation for rectal cancer. Accuracy of transrectal ultrasound was evaluated among 70 patients not receiving preoperative chemoradiation. Forty-seven patients received neoadjuvant chemoradiation based on transrectal ultrasound results. Tumor downstaging and early recurrence were evaluated among 45 of 47 patients receiving neoadjuvant chemoradiation. RESULTS: Among 70 nonirradiated patients, 19 were pathologic Stage pT3. Transrectal ultrasound correctly identified 18 of 19 patients with Stage pT3 (sensitivity, 94.7 percent). Transrectal ultrasound correctly identified 44 of 51 patients with less than pT3 disease (specificity, 86.3 percent). After preoperative chemoradiation in 45 patients with ultrasound Stage uT3 or uT4 tumors, 56 percent of them experienced a reduction in T stage. Residual nodal disease was found in 31 percent of patients. A complete pathologic response with no residual disease at operation was observed in 22 percent of patients. During a median follow-up period of 21 months after diagnosis, seven patients experienced a recurrence of their disease at a median of 12 months after diagnosis. Five of seven patients with recurrence were among a subgroup of ten patients who both failed to downstage T and had residual nodal disease at operation. CONCLUSION: Transrectal ultrasound is an accurate modality for selecting patients for neoadjuvant treatment. Preoperative chemoradiation produced downstaging in 56 percent of patients. Factors related to early recurrence included residual nodal disease and failure to downstage T after neoadjuvant chemoradiation.Presented at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 4 to 8, 1998.     

Endoscopic drainage of pancreatic pseudocysts: a long-term follow-up study of 49 patients

BACKGROUND/AIMS: Endoscopic drainage is one of the non-surgical treatment modalities for pancreatic pseudocysts. The aim of the current study was to assess the safety and the utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome were evaluated in a prospective analysis. METHODOLOGY: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications: 2 patients had bleeding, 2 patients had mild pancreatitis, 8 patients had cyst infection, in relation to the presence of necrosis (5 patients) or clogging of the stent (3 patients). Nine patients (20.9%) had recurrence of pseudocysts. Endoscopic drainage was a definitive treatment in 37/49 (75.5%) patients (median follow up: 25.9 months). CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to pancreatic pseudocyst management.     

The diagnostic value of delta-R and delta-Q as positive criteria of the ergometry test in a group of patients with angina pectoris of effort

ECG-exercise tests were performed in 29 patients affected by effort chest pain. All patients underwent coronary angiography and/or revealed positive results in the cycloergometer effort test. The aim of the study was to evaluate ultrasonic variations in the R and Q waves due to maximal effort, so as to increase the information provided by the effort ECG. In the coronary angiographic test, 21 out of 29 patients revealed significant hemodynamic coronary stenosis; 10 patients were affected by previous myocardial necrosis; 8 patients showed no hemodynamic coronary lesions (OV). In the OV patients a statistically significant increase was observed in the Q wave at maximal effort in comparison with average basal values; on the other hand, there was a decrease, although not significant, in voltage at peak effort in patients with coronary stenosis. R wave amplitude was smaller in comparison to basal values in OV patients, while a significant increase was observed in the 21 patients with coronary lesions.     

A syndrome resembling idiopathic thrombocytopenic purpura in 10 patients with diverse forms of cancer

Ten patients with diverse forms of carcinoma (six patients) and of cancer in the lymphoid system (four patients) presented with or subsequently had a syndrome resembling idiopathic thrombocytopenic purpura (ITP). These patients were older than patients who had ITP alone. ITP was coincident with a diagnosis of cancer (three patients), preceded a diagnosis of cancer (three patients) or followed a diagnosis of cancer (four patients). No patients responded to steroid therapy permanently. Therefore, the course of our patients was fairly typical of ITP in the adult. Since we found nine patients with cancer in a survey of 52 consecutive patients with ITP in the adult population admitted to one hospital, this diagnosis may be missed with some frequency; the development of thrombocytopenia being attributed to other causes.     

Clinical course of collagenous colitis over a period of 10 years

AIM: The aim of this study was to evaluate the long-term outcome of patients with collagenous colitis 10 years after the diagnosis. PATIENTS AND METHODS: In 1989/1990, 65 patients were diagnosed to have collagenous colitis. Initially and after an interval of ten years these patients were asked to complete a questionnaire including onset and duration of diarrhea, stool frequency and consistency, other gastrointestinal symptoms including weight loss, drug history, treatment response and concomitant diseases. RESULTS: Questionnaires from 47 patients (72.3 %) (female 40; mean age 68 years, range 41 - 95 years) were available for analysis. After a follow-up of ten years, 11 patients (23.4 %) had persistent diarrhea with no change of frequency and consistency compared to baseline. Four patients (8.5 %) showed a reduction of diarrhea frequency of at least 50 %. Diarrhea was resolved in 23 patients (48.9 %) during the follow-up period. Of those, 20 patients received anti-inflammatory treatment. After a complete resolution of diarrhea during the long-term follow-up, 9 patients (19.2 %) showed recurrence of diarrheal symptoms. None of the patients developed any malignancies of the GI-tract. CONCLUSION: The long-term outcome of CC is benign with a resolution of diarrhea in up to 50 % of patients receiving anti-inflammatory treatment. About 30 % of patients may experience persistent diarrhea even 10 years after diagnosis. Our data confirm that CC is a chronic disorder with a variable course of symptoms during a long-term follow-up.     

支气管动脉栓塞治大咯血38例临床研究

目的观察支气管动脉栓塞术对大咯血患者的临床疗效。方法 2000年至2008年因大咯血住院患者,经胸部影像学检查或纤维支气管镜、支气管动脉造影明确诊断的患者行支气管动脉栓塞术。结果共38例患者,男26,女12例,年龄56±9岁,反复咯血31例,支气管扩张27例,支气管肺囊肿4例,不明原因4例,肺结核3例。支气管动脉造影均表现为血管畸形,给予支气管动脉栓塞治疗35例出血立即减少,1周内完全消失。随访1年,复发大咯血2例。治疗后3例短时间内轻微胸痛,2例肩痛,3例伴胸闷,3例腹股沟皮下淤血,对症处理后短期内好转。结论支气管动脉栓塞术对治疗急性或反复发生的大咯血非常有效,可以使患者避免外科手术的风险,对复发患者再次治疗也安全有效。     

Determination of the value of Na+/H+-metabolism in erythrocytes of patients with arterial hypertension of endocrine origin]

The paper is concerned with the results of determination of a value of Na+/H(+)-metabolism in 66 patients with arterial hypertension of different genesis, including 21 patients with stage 11 essential hypertension, 8 patients with renal hypertension, 25 patients with Itsenko-Cushing syndrome or disease, 7 patients with pheochromocytoma, and 5 patients with primary hyperaldosteronism. The control group consisted of 11 healthy persons without predisposition to essential hypertension. It was shown that a value of Na+/H(+)-metabolism in patients with essential hypertension exceeded a 3.8-fold the control values. In patients with hyperglucocorticism, pheochromocytoma, arterial hypertension of renal genesis, the rate of Na+/H(+)-metabolism was significantly decreased as compared to that of a group of patients with essential hypertension. It could be used in differential diagnosis of the hypertensive syndrome. The problem of the diagnostic value of this indicator in primary hyperaldosteronism needs further investigation.     

The peripheral circulation and treatment of hyperlipoproteinemias

Forty patients with hyperlipoproteinemia were followed 4-9.3 years by non-invasive tests of their lower extremity circulation. Twenty-eight patients were treated by diet and/or drugs, and 12 patients were controls. Although all patients had abnormal non-invasive tests, only 15 patients had intermittent claudication. Seven patients had improved circulation tests while 13 showed a deterioration in the tests; 20 patients had no changes. The patients who showed improvement in tests had the highest incidence of intermittent claudication and the lowest average ankle to brachial artery systolic blood pressure index. Although treatment patients had a significant decrease in total cholesterol, triglycerides, and VLDL, no significant differences were found when the results of the circulation tests were analyzed according to treatment or control status of the patients, to abnormal lipid patterns, or, ignoring treatment status, to a decrease in lipids. The patients who showed a deterioration in tests had a significantly higher total cholesterol level at the beginning of, but not during, the study and did not significantly decrease their triglycerides. No significant changes occurred in HDL, LDL, or VLDL. This study presents a methodology for the long-term, non-invasive assessment of peripheral arterial disease and a pilot study for its application. Despite the small number of patients studied, the failure to demonstrate benefit would discourage a larger clinical trial of this treatment protocol.