Predicting which patients can undergo upper endoscopy comfortably without conscious sedation

BACKGROUND: Eliminating conscious sedation for diagnostic endoscopy may be advantageous for patient safety and cost containment. The aim of this study was to identify and validate independent predictors of a comfortable, technically adequate, unsedated diagnostic upper endoscopy in Canadian patients. METHODS: Patients were consecutively enrolled in a prospective fashion. Data collected on an initial cohort of 268 patients included demographics, a validated anxiety questionnaire, use of sedatives/analgesics, upper endoscopy experience, pharyngeal sensitivity, technical adequacy, and patient assessment of comfort after the procedure. The main outcome measure was "satisfactory upper endoscopy," a composite of optimal scores for patient comfort and technical adequacy. Univariate and multivariate analyses were performed to identify the optimal predictive model of a satisfactory unsedated diagnostic upper endoscopy. Once identified, 68 additional patients were enrolled in a similar fashion from an independent prospective sample for purposes of outcome validation. Multivariate analysis was then repeated with the total cohort (N = 336). These results were then compared for concordance with those obtained from the initial cohort. RESULTS: Among the initial 268 patients (54.3% women; mean age 51 +/- 17 years), 49% were anxious, 15% regularly used sedatives and analgesics, 28% experienced increased pharyngeal sensitivity, and 41% had previously undergone upper endoscopy. Endoscopy was completed in 94.7% of patients without sedation and was technically adequate in 97%, and 80.1% were willing to repeat the procedure under similar conditions. Satisfactory upper endoscopy was achieved in only 59% of the initial cohort. The only independent and significant predictors of a satisfactory upper endoscopy were advancing age (OR 1.2: 95% CI [1.1, 1.4]) and decreased pharyngeal sensitivity (OR 0.5: 95% CI [0.27, 0.93]). Concordance of results were noted after validation with the second cohort. Satisfactory endoscopy was achieved in only 59.5% of the total cohort (n = 336); only 61% reported a comfortable procedural experience. CONCLUSIONS: The proportion of patients who can comfortably undergo technically adequate unsedated upper endoscopy is modest. Unsedated upper endoscopy is most likely to be successful under these procedural conditions in patients of advancing age with decreased pharyngeal sensitivity. The generalizability of these findings to an American population requires further study and may assist in identifying a subgroup of patients in whom it is cost-effective to perform upper endoscopy comfortably without sedation.     

Simultaneous cerebrospinal fluid otorrhea and rhinorrhea as a cause of recurrent meningitis in a patient with cochlear dysplasia

Inner ear dysplasia is a rare cause of cerebrospinal fluid otorhinorrhea and presents in a variety of ways, ranging from asymptomatic to recurrent bacterial meningitis. We describe a 6-year-old boy who presented with clear watery nasal discharge and recurrent bacterial meningitis. Magnetic resonance cisternogram showed cerebrospinal fluid leak through the cribriform plate of ethmoid. High-resolution computed tomographic scan of temporal bones confirmed the diagnosis of cochlear dysplasia, with cerebrospinal fluid leak coming through a defect near the oval window and through the eustachian tube orifice into the nose. Surgical closure of the defects was performed successfully. CONCLUSION: Recurrent meningitis in a child should be investigated for inner ear malformations. Awareness of this condition, a high index of suspicion and early imaging can prevent complications and give excellent results in these children.     

Effect of short term vitamin A deficiency on organ weights, blood glucose and lactate levels and, tissue protein and glycogen contents of albino rats: a preliminary study

The effect of short term dietary vitamin A deficiency in post-pubertal female rats in terms of weight gain, food consumption, organ weights, haemoglobin content, blood glucose and lactate levels and, tissue protein and glycogen contents has been evaluated to gain insight into the possible interrelationship between vitamin A and general metabolism. Significant elevation in blood glucose level and reduction in blood lactate and haemoglobin along with a tendency of reduction in weights of spleen, adrenals and ovaries have been noted. Lowered tissue protein and glycogen contents and reduced body weight gain have also been revealed. Obviously, reduced functional competence of some of the organs and certain alterations in general metabolism especially of carbohydrates are suspected and hence is discussed in relation to supportive evidences available.     

Tuberculosis of paranasal sinuses

Nasal tuberculosis is very rare but much rarer is tuberculosis of paranasal sinuses. It involves especially the maxillary sinus and is usually unilateral. We report an unusual case of tuberculosis of frontal and maxillary sinus in a 68 years old male, who presented with a swelling above left medial canthus, with no other eye or nasal complaints. Clinical and radiological findings on our initial evaluation suggested that the patient had left frontal mucocoele with bilateral maxillary haziness. Diagnosis was established on FNAC report and subsequent Ziehl — Neelsen staining of nasal swabs and tuberculin skin test. Later chest x-ray examination was suggestive of pulmonary tuberculosis, which was the primary cause. Patient responded well to antituberculosis drug therapy.     

Foreign body inhalation in children: Decisive factors for carrying out bronchoscopy

Inhalation of Foreign Body is one of the most common causes of accidental death at home in the paediatric age group. There may not be a clear history of foreign body inhalation and the patient may be asymptomatic at initial presentation. This coupled with the failure of radiological investigations on most occasions makes this a vexing clinical situation. These apparently normal children almost invariably have a bad prognosis if the foreign body is ignored. This study aims to define the most important factors influencing the decision to carry out the definitive surgery, i.e., bronchoscopy, which can be diagnostic as well as therapeutic, based on our experience with 50 cases of suspected FB in the tracheobronchial tree from January 2001 to July 2003. Results from the study suggest that radiological investigations have only limited value in deciding the management of a patient with suspected Foreign Body inhalation. This should not influence the decision to carry out a bronchoscopy, which should rather be based on history and clinical examination.     

Aggression and Dominance: The Roles of Power and Culture in Domestic Violence

In the past few decades, it has become increasingly clear to social scientists and policy makers alike that violence within the family is all too common and carries enormous costs to individuals, families, and society as a whole. Numerous controversies exist in the field, particularly with regard to what factors are significant in the etiology and development of violence between intimate partners. This article focuses on relationship power as a critical construct to consider in domestic violence, as it encompasses aspects of social, dyadic, and individual functioning. The literature on the construct of power and its relationship to domestic violence is reviewed and then placed in cultural context, followed by a discussion of future directions for research on and treatment issues in power and violence.     

Effect of adrenalectomy on rat epididymidis

Aim: To investigate the effect of adrenalectomy (ADX) on the epididymidis of Sprague-Dawley rats. Methods: The histological, biochemical (cholesterol protein, zinc, copper, alkaline and acid phosphatase aryl sulphatase, lactic dehydrogenase and leucine amino peptidase) and hormonal (FSH, LH and testosterone) changes of caput and cauda epididymis in ADX rats were observed. Results: Organ wet weight, histological studies and morphometric measurements indicated a cellular degeneration in caput and cauda epididymis of ADX rats. Serum testosterone level was significantly lower in ADX than in sham-operated rats, while the serum FSH and LH were below the detection limit of 1 mIU/mL. The enzymatic activity was higher in ADX than in sham-operated rats. Epididymal zinc level increased whereas copper level decreased in ADX rats compared to the sham-operated. Conclusion: Adrenalectomy leads to degeneration of caput and cauda epididymidis epithelial cells as a result of decreased supply of testosterone. (Asian J And     

Megakaryocyte colony stimulating activity in allogeneic bone marrow recipients prepared with busulfan and cyclophosphamide

Summary Increased megakaryocyte colony stimulating activity (MK-CSA) has been reported after total body irradiation (TBI) for bone marrow transplant (BMT). We studied the effect of a busulfan (Bu) and cyclophosphamide (Cy) marrow transplant conditioning regimen, without radiation, on MK-CSA production. Initial screening of MK-CSA was done on previously collected and banked sera from 14 BMT patients. MK-CSA was expressed as the ability to stimulate growth of megakaryocyte progenitors (CFU-MK) in standard plasma clot cultures. In the initial samples, MK-CSA peaked at day 7. This preliminary data led to a prospective study of MK-CSA and clinical parameters in seven allogeneic recipients. MK-CSA activity increased from day −7 pre-transplant (2.9 ± 1.7 CFU-MK/10⁵ NATD, mean ± SD) to day O (10.3 ± 4.7 CFU-MK) and peaked by day 9 post-transplant (20.6 ± 6.4 CFU-MK). MK-CSA activity decreased in all seven patients by day 21 at which time five of seven patients studied had recovery of platelet counts to greater than 100 ± 10⁹/l. MK-CSA activity rose rapidly in both groups of sera after the initiation of this non-irradiation. BMT preparative regimen. High MK-CSA levels, early after transplant, may contribute to the rapid platelet recovery in some patients.