Rapid improvement in post-infectious gastroparesis symptoms with mirtazapine

We report the case of a 34-year-old woman with severe post-infectious gastroparesis who was transferred from an outside medical facility for a second opinion regarding management.This patient had no prior history of gastrointestinal symptoms.However,in the aftermath of a viral illness,she developed two months of intractable nausea,vomiting,and oral intake intolerance that resulted in numerous hospitalizations for dehydration and electrolyte disturbances.A solid-phase gastric emptying scan had confirmed delayed emptying,confirming gastroparesis.Unfortunately,conventional pro-kinetic agents and numerous anti-emetic drugs provided little or no relief of the patient’s symptoms.At our institution,the patient experienced a cessation of vomiting,reported a significant reduction in nausea,and toler-ated oral intake shortly after taking mirtazapine.Based on mirtazapine’s primary action as a serotonin(5-HT)1a receptor agonist,we infer that this receptor system mediated the clinical improvement through a combination of peripheral and central neural mechanisms.This report highlights the potential utility of 5-HT1a agonists in the management of nausea and vomiting.We conclude that mirtazapine may be effective in treating symptoms associated with non-diabetic gastroparesis that are refractory to conventional therapies.     

Quantitative Ultrasound and Mortality: A Prospective Study

Previous studies suggest that low bone mineral density (BMD) is associated with increased mortality, but the relationship between quantitative ultrasound (QUS) and mortality is unknown. We studied 5816 women over age 70 years enrolled in the Study of Osteoporotic Fractures. QUS of the calcaneus, and BMD of the calcaneus and hip, were measured at baseline, and women were contacted every 4 months to determine vital status. All reported deaths were confirmed by review of the death certificate or hospital records, and classified by ICD-9 code. During 5.0 years of follow-up, 677 women died. Women in the lowest quintile of QUS had the highest mortality during follow-up. After adjustment for age, grip strength, weight, height, health status, estrogen use, smoking, physical activity, and history of hypertension, diabetes, cardiovascular disease, cancer and stroke, each 1 SD reduction in broadband ultrasonic attenuation (BUA) was associated with a 16% increase in mortality (RH = 1.16; 95% CI: 1.07, 1.26). Mortality from cardiovascular disease, cancer and other causes were all increased among women with low QUS, but the association with cancer deaths was not statistically significant after multiple adjustments (RH = 1.09; CI: 0.93, 1.27). Low BMD was also associated with an increased risk of total and cause-specific mortality, but we found little evidence that BUA and BMD were independent predictors of mortality. Results were similar among women who did not fracture during follow-up. In this large population-based study of older women, low QUS is associated with both total and cause-specific mortality. This relationship was independent of other factors associated with mortality, such as age and health status, and suggests QUS and BMD may reflect some aspect of aging not captured by these traditional factors. Received: 16 March 2001 / Accepted: 19 February 2002     

Lipid and blood pressure treatment goals for type 1 diabetes: 10-year incidence data from the Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE--Subjects with type 1 diabetes are at high risk for many long-term complications, including early mortality and coronary artery disease (CAD). Few data are available on which to base goal levels for two major risk factors, namely blood pressure and lipid/lipoproteins. The objective of this study was to determine at which levels of LDL and HDL cholesterol, triglycerides, and blood pressure the relative risks of type 1 diabetic complications increase significantly. RESEARCH DESIGN AND METHODS--Observational prospective study of 589 patients with childhood-onset type 1 diabetes (<17 years) aged > or =18 years at baseline; 10-year incidence of mortality, CAD, lower-extremity arterial disease, proliferative retinopathy, distal symmetric polyneuropathy, and overt nephropathy. Relative risks were determined using traditional groupings of blood pressure and lipid/lipoproteins, measured at baseline, using the lowest groupings (<100 mg/dl [2.6 mmol/l] LDL cholesterol, <45 mg/dl [1.1 mmol/l] HDL cholesterol, <100 mg/dl [1.1 mmol/l] triglycerides, <110 mmHg systolic blood pressure, and <80 mmHg diastolic blood pressure) as reference. Adjustments for age, sex, and glycemic control were examined. RESULTS--Driven mainly by strong relationships (RR range 1.8-12.1) with mortality, CAD, and overt nephropathy, suggested goal levels are as follows: LDL cholesterol <100 mg/dl (2.6 mmol/l), HDL cholesterol >45 mg/dl (1.1 mmol/l), triglycerides <150 mg/dl (1.7 mmol/l), systolic blood pressure <120 mmHg, and diastolic blood pressure <80 mmHG: Age, sex, and glycemic control had little influence on these goals. CONCLUSIONS--Although observational in nature, these data strongly support the case for vigorous control of lipid levels and blood pressure in patients with type 1 diabetes.     

Group-Based Trajectory Modeling of Suppression Ratio After Cardiac Arrest

Background

Existing studies of quantitative electroencephalography (qEEG) as a prognostic tool after cardiac arrest (CA) use methods that ignore the longitudinal pattern of qEEG data, resulting in significant information loss and precluding analysis of clinically important temporal trends. We tested the utility of group-based trajectory modeling (GBTM) for qEEG classification, focusing on the specific example of suppression ratio (SR).

Methods

We included comatose CA patients hospitalized from April 2010 to October 2014, excluding CA from trauma or neurological catastrophe. We used Persyst^®v12 to generate SR trends and used semi-quantitative methods to choose appropriate sampling and averaging strategies. We used GBTM to partition SR data into different trajectories and regression associate trajectories with outcome. We derived a multivariate logistic model using clinical variables without qEEG to predict survival, then added trajectories and/or non-longitudinal SR estimates, and assessed changes in model performance.

Results

Overall, 289 CA patients had ≥36 h of EEG yielding 10,404 h of data (mean age 57 years, 81 % arrested out-of-hospital, 33 % shockable rhythms, 31 % overall survival, 17 % discharged to home or acute rehabilitation). We identified 4 distinct SR trajectories associated with survival (62, 26, 12, and 0 %, P < 0.0001 across groups) and CPC (35, 10, 4, and 0 %, P < 0.0001 across groups). Adding trajectories significantly improved model performance compared to adding non-longitudinal data.

Conclusions

Longitudinal analysis of continuous qEEG data using GBTM provides more predictive information than analysis of qEEG at single time-points after CA.

     

Liver regeneration after liver resection: Clinical aspects and correlation with infective complications

AIM:To investigate whether early liver regeneration after resection in patients with hepatic tumors might be influenced by post-operative infective complications.METHODS:A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010.Regeneration was evaluated by multidetector computed tomographyat a mean follow-up of 43.85 d.The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 mo after transplantation,and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data.Generalized linear regression models with Gaussian family distribution and log link function were used to reveal the principal promoters of early liver regeneration.RESULTS:Ten of the 27 patients(37%)underwent chemotherapy prior to surgery,with a statistically significant prevalence of patients with metastasis(P=0.007).Eight patients(30%)underwent embolization,3 with primary tumors,and 5 with secondary tumors.Twenty patients(74%)experienced complications,with 12(60%)experiencing Clavien-Dindo Grade 3a to 5 complications.Regeneration≥100%occurred in 10(37%)patients.The predictors were smaller future remnant liver volume(-0.002;P<0.001),and a greater spleen volume/future remnant liver volume ratio(0.499;P=0.01).Patients with a resection of≥5 Couinaud segments experienced greater early regeneration(P=0.04).Nine patients experienced surgical site infections,and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected(P=0.016).There were no significant differences between patients with primary or secondary tumors,and either onset or infections or severity of surgical complications.CONCLUSION:Regardless of the onset of infective complications,future remnant liver and spleen volumes may be reliable predictors of early liver regeneration after hepatic resection on an otherwise healthy liver.     

E‐Learning Module on Chronic Low Back Pain in Older Adults: Evidence of Effect on Medical Student Objective Structured Clinical Examination Performance

The Institute of Medicine has highlighted the urgent need to close undergraduate and graduate educational gaps in treating pain. Chronic low back pain (CLBP) is one of the most common pain conditions, and older adults are particularly vulnerable to potential morbidities associated with misinformed treatment. An e‐learning case‐based interactive module was developed at the University of Pittsburgh Center of Excellence in Pain Education, one of 12 National Institutes of Health–designated centers, to teach students important principles for evaluating and managing CLBP in older adults. A team of six experts in education, information technology, pain management, and geriatrics developed the module. Teaching focused on common errors, interactivity, and expert modeling and feedback. The module mimicked a patient encounter using a standardized patient (the older adult with CLBP) and a pain expert (the patient provider). Twenty‐eight medical students were not exposed to the module (Group 1) and 27 were exposed (Group 2). Their clinical skills in evaluating CLBP were assessed using an objective structured clinical examination (OSCE). Mean scores were 62.0 ± 8.6 for Group 1 and 79.5 ± 10.4 for Group 2 (P < .001). Using an OSCE pass–fail cutoff score of 60%, 17 of 28 Group 1 students (60.7%) and 26 of 27 Group 2 students (96.3%) passed. The CLBP OSCE was one of 10 OSCE stations in which students were tested at the end of a Combined Ambulatory Medicine and Pediatrics Clerkship. There were no between‐group differences in performance on eight of the other nine OSCE stations. This module significantly improved medical student clinical skills in evaluating CLBP. Additional research is needed to ascertain the effect of e‐learning modules on more‐advanced learners and on improving the care of older adults with CLBP.     

Thyroid hormone use, hyperthyroidism and mortality in older women

Purpose

Thyroid dysfunction is common, particularly among older women. The safety of thyroid hormone use and long-term prognosis of hyperthyroidism remain controversial. We performed a prospective cohort study to examine the relationship among thyroid hormone use, previous hyperthyroidism, abnormal thyroid function, and mortality.

Methods

We studied 9449 community-dwelling white women aged ≥65 years followed for 12 years. For analyses of thyroid function, we performed a nested case-cohort in 487 women using a third-generation thyroid-stimulating hormone assay. Causes of death were adjudicated based on death certificates and hospital records.

Results

Twelve percent of the 9449 women took thyroid hormone at baseline, and the mean duration of thyroid hormone use was 15.8 years; 9.4% of participants reported a history of hyperthyroidism. During 12 years of follow-up, 3159 women died (33%). In multivariate analysis, mortality among users of thyroid hormone was similar to that observed for nonusers (relative hazard [RH] 1.11, 95% confidence interval [CI], 0.98-1.24, P = .09). Previous hyperthyroidism was associated with a higher risk of all-cause mortality (RH 1.20, 95% CI, 1.06-1.36), particularly cardiovascular mortality (RH 1.46, 95% CI, 1.20-1.77). Low (≤0.5 mU/L) or high (>5 mU/L) thyroid-stimulating hormone levels were not associated with excess total or cause-specific mortality, but the power to detect these relationships was limited.

Conclusions

Among older women, thyroid hormone use is not associated significantly with excess mortality, but previous hyperthyroidism may be associated with a small increase in all-cause and cardiovascular mortality. Additional long-term studies of hyperthyroidism and its treatment should further explore these findings.     

Ethics of triage in the event of an influenza pandemic

The prospect of a severe influenza pandemic poses a daunting public health threat to hospitals and the public they serve. The event of a severe influenza pandemic will put hospitals under extreme stress; only so many beds, ventilators, nurses, and physicians will be available, and it is likely that more patients will require medical attention than can be completely treated. Triage is the process of sorting patients in a time of crisis to determine who receives what level of medical attention. How will hospitals sort patients to determine priority for treatment? What criteria will be used? Who will develop these criteria? This article formulates an answer to these questions by constructing a conceptual framework for anticipating and responding to the ethical issues raised by triage in the event of a severe influenza pandemic.