Do medicine residents triage patients with gastrointestinal bleeding appropriately?

Background: Gastrointestinal specialists depend on internal medicine (IM) teams to accurately identify acute gastrointestinal bleeding (GIB). We evaluated whether IM residents’ assessment of GIB correlated with the impressions of GI specialists during consultations at an inner-city university teaching hospital. Methods: A questionnaire was distributed to house staff requesting GIB consultations and to the GI fellows performing the consults between August 2011 and April 2012. Residents and fellows were asked to assess GIB, specifically melena, using a stool color card and digital rectal examination (DRE) findings. Fellow DRE findings served as controls for stool color identification. Results: Eighty-seven GI consults were eligible for the study. Residents and fellows completed 81 and 86 questionnaires, respectively. A total of 76 questionnaires were included for analysis. A DRE was performed by medical staff before calling a consult in 65% of cases compared with fellows (97% of cases, P = 0.0001). Residents more frequently labeled stool as melena (42%) in patients as compared with fellows (12%, P = 0.0001). Residents inaccurately identified melenic stools in 22 patients (11 based on stool color and 11 based on DRE findings). Residents were more likely to label a consult as emergent than fellows (13.5% vs 4%, P < 0.05). Conclusion: Residents are less likely to perform DRE during an evaluation for GIB and to accurately identify melena based on stool color or DRE findings. There appears to be a need to educate residents on the appropriate terminology for stool color and the importance of DRE to accurately triage patients with acute GIBs.     

Lifestyle Patterns Are Associated with Elevated Blood Pressure among Qatari Women of Reproductive Age: A Cross-Sectional National Study

Women of childbearing age are particularly vulnerable to the adverse effects of elevated blood pressure (BP), with dietary and lifestyle habits being increasingly recognized as important modifiable environmental risk factors for this condition. Using data from the National STEPwise survey conducted in Qatar in year 2012, we aimed to examine lifestyle patterns and their association with elevated BP among Qatari women of childbearing age (18–45 years). Socio-demographic, lifestyle, dietary, anthropometric and BP data were used (n = 747). Principal component factor analysis was applied to identify the patterns using the frequency of consumption of 13 foods/food groups, physical activity level, and smoking status. Multivariate logistic regression analyses were used to evaluate the association of the identified lifestyle patterns with elevated BP and to examine the socio-demographic correlates of these patterns. Three lifestyle patterns were identified: a “healthy” pattern characterized by intake of fruits, natural juices, and vegetables; a “fast food & smoking” pattern characterized by fast foods, sweetened beverages, and sweets, in addition to smoking; and a “traditional sedentary” pattern which consisted of refined grains, dairy products, and meat in addition to low physical activity. The fast food & smoking and the traditional & sedentary patterns were associated with an approximately 2-fold increase in the risk of elevated BP in the study population. The findings of this study highlight the synergistic effect that diet, smoking and physical inactivity may have on the risk of elevated BP among Qatari women.     

Effects of Lepidium sativum,Nigella sativa and Trigonella foenum‐graceum on Phenytoin Pharmacokinetics in Beagle Dogs

The present work was designed to evaluate the effect of some commonly used herbs viz. garden cress (Lepidium sativum), black seed (Nigella sativa) and fenugreek (Trigonella foenum‐graceum) on the disposition of phenytoin after oral administration in a dog model. Phenytoin was given orally at a dose of 50 mg, and blood samples were obtained for the determination of drug's pharmacokinetic parameters. After a suitable washout period, animals were commenced on a specific herb treatment for one week. Garden cress treatment caused a modest increase in maximum observed concentration (C_max) and terminal half‐life (T_1/2λ) of phenytoin with a reduction in clearance by 33%. The effect of black seed therapy was more drastic on drug elimination and to a lesser extent on its volume of distribution at steady state (V_ss) with a consequent reduction in systemic exposure measured by area under the curve (AUC_0‐∞) by about 87%. The effect of fenugreek therapy resembled, albeit to a lesser extent, that of black seed with a significant reduction in AUC_0‐∞ by ~72%. In addition, there was a 73% increase in V_ss. Our findings suggest that the phenytoin disposition can be significantly altered by the concurrent consumption of tested herbal products. Copyright © 2013 John Wiley & Sons, Ltd.     

A successful chronic care program in Al Ain-United Arab Emirates

Background

The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates.

Settings and Methods

The project, using the principles of quality assurance cycles, was conducted in 4 stages. The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development. In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education.

Results

The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history (e.g. smoking status and physical activity); improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve.

Conclusion

Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement.     

Anti-inflammatory effects of long-chain n-3 PUFA in rhinovirus-infected cultured airway epithelial cells

Long-chain n-3 PUFA (LCn-3PUFA) including DHA and EPA, are known to decrease inflammation by inhibiting arachidonic acid (AA) metabolism to eicosanoids, decreasing the production of pro-inflammatory cytokines and reducing immune cell function. The aim of this study was to determine if EPA and DHA reduced the release of inflammatory mediators from airway epithelial cells infected with rhinovirus (RV). Airway epithelial cells (Calu-3) were incubated with EPA, DHA and AA for 24 h, followed by rhinovirus infection for 48 h. IL-6, IL-8 and interferon-gamma-induced protein-10 (IP-10) released by cells were measured using ELISA. Viral replication was measured by serial titration assays. The fatty acid content of cells was analysed using GC. Cellular viability was determined by visual inspection of cells and lactate dehydrogenase release. DHA (400 microm) resulted in a significant 16% reduction in IL-6 release after RV-43 infection, 29% reduction in IL-6 release after RV-1B infection, 28% reduction in IP-10 release after RV-43 infection and 23 % reduction in IP-10 release after RV-1B infection. Cellular DHA content negatively correlated with IL-6 and IP-10 release. None of the fatty acids significantly modified rhinovirus replication. DHA supplementation resulted in increased cellular content of DHA at the cost of AA, which may explain the decreased inflammatory response of cells. EPA and AA did not change the release of inflammatory biomarkers significantly. It is concluded that DHA has a potential role in suppressing RV-induced airway inflammation.     

Impact of olive oil-rich diet on serum omentin and adiponectin levels: a randomized cross-over clinical trial among overweight women

This study aimed to investigate the effect of olive oil-rich diet on omentin and adiponectin concentrations. This cross-over randomized trial included 17 overweight women. Participants were assigned to consume either a usual (16% saturated fatty acids [SFA] and 8% monounsaturated fatty acid [MUFA]) or an olive oil-rich diet (16% MUFA and 8% SFA) for 6 weeks crossing over after a 2-week washout period. There was no significant difference in the changes of omentin between two dietary interventions. However, in the adjusted model for polyunsaturated fatty acids and fat mass, usual diet tended to decrease omentin levels whilst olive oil-rich diet tended to increase (?56.1?±?32.0 versus 40.6?±?32.0?ng/mL; p?=?.056). Adiponectin levels increased during two periods, but changes were greater during olive oil-rich diet with a trend toward significance (4.8?±?3.0 versus 13.4?±?3.0?μg/mL; p?=?.06). Consumption of olive oil-rich diet tended to increase omentin and adiponectin in comparison with the usual diet.     

Health shock,catastrophic expenditure and its consequences on welfare of the household engaged in informal sector

Purpose

Despite significant contribution by India’s informal sector, tattered conditions have inflated the burden of health shocks in many ways. This study tries to examine the economic burden of health shocks and its associated consequences on households whose members are involved in informal sector. We primarily focus on three objectives for our analysis: (1) compute distribution and magnitude of health shocks and health expenditure between formal and informal workers; (2) evaluate the incidence and intensity of catastrophic health expenditure (CHE), and measure its impoverishment effect; (3) estimate the major determinants of CHE for informal sector households.

Methods

Underlying objectives have been estimated using standard catastrophic and impoverishment measures (poverty headcount and poverty gap) and Poisson, logit and Tobit multivariate regression models. For empirical analysis, data is exploited from the recent round of Indian Human Development Survey (IHDS-II), 2012.

Results

We find that around 27% of households engaged in the informal sector spends more than 5% threshold on their health payment. We also find that OOP health expenditure pushes 7.12% informal sector households in poverty. Moreover, we also find that the impoverishment effect mainly rests on outpatient health expenditure and poverty deepening for informal sector households.

Conclusion

Our findings indicate that informal sector workers are highly vulnerable to health shocks and economic burden in terms of high treatment costs and low insurance coverage. Further, we also show that workers engaged in the informal sector witness greater probability of incurring CHE and impoverishment. Results from the Tobit model suggests that various factors such as insurance coverage, severity of illness and others are crucial predictor of catastrophic spending.

     

Anti-inflammatory,analgesic activity and acute toxicity of Glaucium grandiflorum extract

The species of Glaucium have been used in Iranian herbal medicine as laxative, hypnotic, antidiabetic agents and also in the treatment of dermatitis. The anti-inflammatory and analgesic effects of the aerial parts of Glaucium grandiflorum Boiss & Huet (Papaveraceae), a native plant of Iran, were studied using carrageenan induced edema, formalin and hot plate tests. The G. grandiflorum extract at the dose of 200 mg/kg had more edema inhibition than indomethacin at the doses of 10 (P<0.01) and 8 mg/kg (P<0.001) in the carrageenan test. The ED₅₀ (i.p.) in the edema induced by carrageenan was 13.59 mg/kg. In formalin test, the extract (60–90 mg/kg, i.p.) caused graded inhibition of both phases of formalin-induced pain. In hot plate test, the i.p. administration of the extract at the doses of 60, 70, 80 and 90 mg/kg significantly raised the pain threshold at a observation time of 45 min in comparison with control (P<0.001). The extract, at the antinociceptive doses, did not affect motor coordination of animals when assessed in the rotarod model. The 72 h acute LD₅₀ value of this extract after i.p. administration in mice was 797.94 mg/kg.     

Interleukin-11 Overexpression and M2 Macrophage Density are Associated with Angiogenic Activity in Proliferative Diabetic Retinopathy

ABSTRACT

Purpose

To investigate the expression of IL-11 and its receptor IL-11Rα and to quantify density of CD163⁺ M2 macrophages in proliferative diabetic retinopathy (PDR).