Gastrointestinal bleeding during an ultramarathon

Digestive symptoms and gastrointestinal bleeding occur in endurance runners and may contribute to runner's anemia. The cause is unknown, but the frequency of fecal blood loss has been reported to be 8–23% of marathon runners (1–7). Races of longer distances have not been investigated. An ultramarathon is a race that is longer than the 26.2 miles of a marathon and commonly involves distances of 30–100 or more miles and can last 24 hr or more. It differs from the marathon in duration, pace, and intrarace diet. The Old Dominion One Hundred Mile Endurance Run is held in the mountains of Virginia each June. It is open only to experienced ultrarunners who have completed a 50-mile race in less than 9 hr. This race offers a unique opportunity to study highly trained individuals undergoing a tremendous stress to not only their cardiovascular and musculoskeletal systems but also to their gastrointestinal system. The purpose of this prospective study is to determine the incidence of Hemoccult positivity occurring in association with an ultramarathon and evaluating, by means of a questionnaire, cofactors contributing to the gastrointestinal bleeding.The opinions and assertions contained herein are those of the authors and are not to be construed as reflecting the views of Walter Reed Army Medical Center, the Department of the Army or the Department of Defense.     

Does review of peripheral blood smears help in the initial workup of common anemias?

Sixty-five physicians were tested to determine the effect of their reviews of red blood cell morphology on their subsequent diagnoses of and workup plans for common anemias. The subjects read clinical and laboratory data for six pairs of cases of anemia, reviewing the blood smear for one case in each pair. They correctly identified the presence or absence of morphologic features on the blood smears 82% of the time. In spite of excellent morphologic discrimination, the number of tests ordered was not affected by blood smear review. In fact, the quality of the physicians’ workup plans, measured by numbers of tests appropriately ordered and excluded, was slightly but significantly better when they did not review the smears (p<0.005). In addition, smear review did not significantly improve diagnostic accuracy for any of the common anemias studied. Significantly more correct diagnoses were made without smear review for vitamin B₁₂-folate deficiency anemia (p<0.015) and thalassemia (p<0.0001). Although routine review of blood smears by physicians in the management of common anemias may provide useful information, the authors were unable to demonstrate an improvement in the number or appropriateness of tests ordered or diagnostic accuracy in spite of excellent morphologic discrimination. Received from the Divisions of General Internal Medicine and Hematology, Department of Medicine, Walter Reed Army Medical Center, Washington, DC, and the Uniformed Services University of the Health Sciences, Bethesda, Maryland. Dr. Simmons is now Chief, Division of General Internal Medicine, Brooke Army Medical Center, San Antonio, Texas. Presented in part at the annual meeting of the American Federation of Clinical Research, Washington, DC, May 3, 1986. Supported by a grant from the Department of Clinical Investigation (WU 1013), Walter Reed Army Medical Center, Washington, DC 20307-5001. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of Defense, the Department of the Army, or the Uniformed Services University of the Health Sciences.     

Hypotonic duodenoscopy

Inducing duodenal hypotonia by the intravenous injection of propantheline bromide is a simple, safe procedure that will permit this organ to be visualized adequately by endoscopy. Twenty-five consecutive patients with suspected duodenal pathology received an intravenous injection of propantheline at the time the pylorus was being viewed through the endoscope. Immediately after the injection, the pylorus dilated and the endoscope was passed easily into the duodenal bulb, where good visualization was achieved. A small bulb syringe attached to the air channel of the endoscope and gentle insufflation of air permitted good visualization of the second portion of duodenum. While the propantheline method is not necessary in all patients undergoing duodenoscopy, those in whom it is difficult to pass the endoscope through the pylorus or in whom antroduodenal motility precludes adequate examination, injection of the antispasmodic provides one easy, safe method for examining the duodenum by duodenoscopy.     

Enzymatic digestion of esophageal meat impaction

While a solution of Adolph's Meat Tenderizer^® (AMT) is commonly used to treat esophageal meat impaction, few studies describe its clinical effects. We examined AMT with regard to (1) its papain activity; (2) its ability to digest meat cubesin vitro; and (3) its effect on rabbit esophageal mucosa. A standard papain assay was developed against which the activity of AMT was compared. Proteolytic activity was detected in AMT only when the papain activators, 0.02 M cysteine and 0.008 M EDTA, were added to the system. Meat cubes incubated in AMT solution exhibited no evidence of digestion as determined by protein release or change in sample weight. A solution of AMT had no adverse effect on normal esophageal mucosa in rabbits, but significantly increased esophagitis when infused onto previously inflamed mucosa. We conclude that AMT solution has no inherent capacity to digest or to reduce the size of an impacted meat bolus, and may, in fact, worsen existing esophagitis.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.Presented at the Twelfth Annual William Beaumont Gastrointestinal Symposium, March 23–25, 1983, El Paso, Texas.Address for reprint requests: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, California 94129.     

Wound Healing: Effects of Closing Tension,Zyplast™, and Platelet-Derived Growth Factor

Previous studies have shown that beginning 5 to 7 days from wounding, the tensile strength of wounds closed under tension in rats is significantly higher than the tensile strength of wounds closed without tension. This study evaluated the effects of increased closing tension, zyplast implant (ZI), and human recombinant platelet-derived growth factor (PDGF) on the tensile strength of wounds. Six groups of 12 rats each were divided into two main subsets: wounds were closed without tension in three groups and with high tension of approximately 100 g in the three other groups. In both no-tension and high-tension groups, one subgroup received no intervention (controls), one subgroup received ZI (zyplast controls), and one subgroup received ZI-PDGF (ZI used as a carrier for PDGF). Healing was evaluated by tensile strength determinations at 5 days. For the controls, wounds closed under tension showed a trend toward higher tensile strength, but statistical significance was not reached. Compared with controls, tensile strength was 45% lower in the wounds with ZI and closure with tension (P = .0063) and 38% lower in the wounds with ZI and closure without tension (P = .007). Treatment with ZI-PDGF resulted in 69% higher tensile strengths (P = .049) as compared with ZI controls for wounds closed with tension. This study demonstrated the beneficial effect of PDGF in accelerating healing in wounds closed under tension. Although ZI was able to deliver PDGF to the wound, the use of this substance as a carrier is questioned since it was detrimental to healing.     

One urban hospital’s experience with false anthrax exposure disaster response

As a result of our experience, we believe that emergency departments should prepare staff members to recognize and deal with the threat of nuclear, chemical, and biological terrorism. We realize that patients may walk away from an event or use various transportation to the hospital, and thus depending on EMS decontamination teams alone is unrealistic. We have chosen to train all ED personnel (including clerical personnel) to recognize potentially dangerous patients/situations and are expanding this training to include security and information desk staff. We developed a 1-hour videotaped presentation that all ED personnel view during orientation and have added hazardous materials issues to annual competency evaluations. Haz Mat team members have been solicited from throughout the institution and trained following Occupational Safety and Health Administration recommendations. Team members represent a variety of disciplines including nursing, engineering, housekeeping, dietary, respiratory care, EMTs, and paramedics.Additional information and training in domestic preparedness is available from a variety of sources. Partnership with local EMS agencies, fire services, and public health agencies is also helpful. The military and poison centers are invaluable resources for chemical and biological incidents.^{[2] and [5]}     

Charcot-like joints in calcium pyrophosphate dihydrate deposition disease

Two cases of Charcot-like joints in patients with pseudogout who were otherwise neurologically intact are presented. The arthropathy of pseudogout should include Charcot-like joints and it is emphasized that an apparent Charcot joint should raise the question of pseudogout.