Irritable bowel syndrome.

Irritable bowel syndrome is a common gastrointestinal disorder characterized by abdominal pain and a change in bowel habits. It is estimated to occur in 9% to 22% of the US population, and is more often diagnosed in women than in men. There are no diagnostic markers for irritable bowel syndrome and no evidence of organic disease. Moreover, the pathophysiology is not completely understood; however, abnormal gastrointestinal motility, altered sensory activity, central neural dysfunction, psychological disturbances, and luminal factors have been proposed. Treatment requires a multifaceted approach. Education, dietary measures, fiber supplementation, and pharmacological and psychological interventions have been used in the management of this disorder.

Constipation: evaluation and management.

Constipation is a common symptom that can result from several disorders. Most patients with chronic constipation do not have a medical disorder contributing to the constipation and, therefore, require limited evaluation. Initial intervention should include dietary measures and fiber supplements; however, if fiber supplementation is ineffective, other agents can be used. Surgery should be reserved for patients who meet specific clinical criteria.

Colorectal cancer screening.

Colorectal cancer causes significant morbidity and mortality in the United States. The incidence of colorectal cancer increases at age 50, approximately. Risk factors that have been identified include a personal history of colorectal cancer or adenomas, a family history of colon cancer or adenomas, inherited colorectal cancer syndromes, and long standing inflammatory bowel disease. Several screening tests have been developed for colorectal cancer prevention. Surveillance strategy is based on an individual's colorectal cancer risk. This article reviews fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, barium enema, and genetic testing.

Cytomegalovirus hemorrhagic gastritis.

A 36-year-old male with acquired immune deficiency syndrome (AIDS) presented with intractable nausea and vomiting of 1 week's duration that was not attributable to his medications. An esophagogastroduodenoscopy showed hemorrhagic and necrotic gastric mucosa but no ulcers were found. Histopathology revealed viral inclusions consistent with cytomegalovirus (CMV) disease of the stomach. The patient received 6 weeks of intravenous ganciclovir with resolution of symptoms and endoscopic findings. Cytomegaloviral involvement of the stomach is rare, even in immunocompromised patients. Characteristic findings on upper endoscopy are punched-out gastric ulcers. This is a rare case of CMV disease of the stomach presenting as hemorrhagic, necrotic gastritis with inflammatory bridging.

Opportunistic infections. Gastric infections in HIV/AIDS.

Gastric infections in individuals with HIV/AIDS are uncommon. The exact incidence is difficult to determine, since many are asymptomatic. Bacterial, viral, fungal, and protozoan infections have all been reported. However, the likelihood of certain infections is dependent on the degree of immunosuppression. This article will review the diagnosis, clinical manifestations, and treatment of gastric infections in HIV/AIDS.

The effect of nutritional supplementation on survival in seriously ill hospitalized adults: an evaluation of the SUPPORT data. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults. OBJECTIVE: To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective study of preferences, decision-making, and outcomes. SETTING: Five teaching hospitals PARTICIPANTS: 6298 patients aged 18 or older meeting diagnostic and illness severity criteria. MEASUREMENT: Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization. RESULTS: A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42-0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18-2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27-0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38-0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4-1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35-3.42), and COPD (hazard: 1.37; 95%CI, 1.04-1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12-1.59). CONCLUSIONS: Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.

Blood transfusion administration in seriously ill patients: an evaluation of SUPPORT data. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Administration of blood transfusion in seriously ill patients is highly variable. Limited data are available to guide transfusion decisions. OBJECTIVE: To explore characteristics of patients who received blood transfusions and decisions to forego transfusions in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: Prospective study of preferences, decision-making, and outcomes. SETTING: Five teaching hospitals. PARTICIPANTS: 9105 patients aged 18 years and older meeting defined diagnostic and illness severity criteria. MEASUREMENT: Data included blood transfusions, demographic characteristics, diagnoses, comorbid conditions, acute physiology score (APS), nutritional support, and functional status before hospitalization. RESULTS: A total of 2863 patients (31.4%) received blood transfusions, usually early in their hospitalization. Transfused patients were more likely male (57.3 %; P = .008), with a younger mean age (56 vs 64 years), significantly higher APS (P < .001), and significantly lower 2- and 6-month survival predictions (P < .001). The patients with acute respiratory failure or multiorgan system failure with sepsis (1714; 59.9% of all patients receiving transfusions), multiorgan system failure with malignancy (480, 16.8%), and cirrhosis (248, 8.7%) were more likely to receive blood than those with other diseases. Few patients made a decision not to receive blood before (5; 0.05%) or after (126; 1.4%) study entry. Most patients with decisions to forego transfusions also had decisions against trying resuscitation. CONCLUSIONS: Most transfusions occurred in patients with acute respiratory or multiorgan system failure. Few patients decide to forego transfusions. Additional investigation is necessary to evaluate blood transfusion practices in seriously ill patients.

The effects of patient race on outcomes in seriously ill patients in SUPPORT: an overview of economic impact, medical intervention, and end-of-life decisions. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Black Americans have significantly lower life expectancy than white Americans. Racial differences in medical access, management, and DNR orders have been documented. OBJECTIVE: To review the effects of patient race on intervention and end-of-life decisions in seriously ill patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: Review of published analyses from SUPPORT. SETTING: Five teaching hospitals PARTICIPANTS: A total of 9105 patients aged 18 years or older (15% black race) meeting diagnostic and illness severity criteria. MEASUREMENT: Analysis of data collected by chart abstraction and interviews. RESULTS: Blacks reported significant loss in savings, although adjusting for diagnosis and disease severity did not demonstrate significant racial differences. Economic hardship was associated with a preference for comfort care, except in black patients (OR 0.71; CI 95%, 0.57-0.88). Blacks received less intervention with no significant difference in survival. Pain level and control were not affected by race. Blacks were more likely to want CPR, although adjustment for self-pay or Medicaid eliminated racial differences. Blacks were more likely to continue to prefer CPR 2 months after hospitalization (28% vs 17%) and were more likely to change a DNR order to preferring CPR (40 vs 27%). Blacks also more frequently wished to discuss CPR preferences with their physicians but were less likely to have this type of communication (OR 1.53; CI 95%, 1.11-2.11). CONCLUSIONS: Patient race may impact on medical intervention and preferences in seriously ill patients. However, in this population, the differences are of modest clinical importance.

Breast self-examination in women in two primary care settings: an evaluation of the impact of insurance status.

Breast cancer is one of the most common cancers diagnosed among women in the United States. Screening tools available for breast cancer detection include breast self-examination (BSE), clinical breast examination, and mammography. Various studies have indicated that women may inconsistently perform BSE. This investigation evaluated the potential impact of insurance status on BSE. Women with health insurance receiving primary healthcare at a health maintenance organization (HMO) and women without health insurance receiving primary healthcare at a free clinic completed anonymous questionnaires that obtained information about the frequency of BSE performance, whether instruction was given about performing BSE, age at learning BSE, and confidence in performing BSE. One hundred fifty-five (82%) of 200 questionnaires at the HMO and 92 (92%) of 100 questionnaires at the free clinic were completed. Thirty-five percent of women (32% at the HMO, 39% at the free clinic) reported performing BSE. There were no significant differences in the rate of monthly BSE, receiving instruction about performing BSE, age at learning BSE, or confidence in performing BSE in women at the HMO and free clinic. Insurance status did not affect BSE. However, further study is needed to evaluate factors that potentially influence performance of BSE and could encourage compliance with BSE recommendations.

A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency.

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.

Impact of two ambulatory care training programs on smoking-cessation activities.

BACKGROUND: Tobacco use causes significant morbidity and mortality. Resident physicians at the George Washington University Medical Center are trained to counsel patients to stop smoking. METHODS: I retrospectively reviewed charts of 300 patients treated by resident physicians in the Department of Medicine (200) and the Department of Health Care Sciences (100). RESULTS: In the 200 patients cared for by resident physicians in the traditional internal medicine training program, a smoking history was obtained in 93 (47%). Forty-seven patients (51%) smoked, and 7 smokers (15%) were counseled to stop smoking. In 100 patients cared for by resident physicians in the primary care internal medicine training program, a smoking history was obtained in 94 patients (94%). Twenty-three patients (24%) smoked, and 11 (48%) were counseled to stop smoking. CONCLUSION: Resident physicians in the primary care training program obtained more smoking histories and counseled more patients to stop smoking. Further study is necessary to evaluate strategies that can be used in residency training to encourage smoking-cessation counseling.

Colorectal cancer surveillance in African-American and white patients at an urban university medical center.

Colorectal cancer causes significant morbidity and mortality in the United States. Recommendations for colorectal cancer screening have been developed. This study evaluated the colorectal cancer screening practices of African-American and white patients by internal medicine resident physicians. A retrospective chart review was conducted during 1989-1994. The performance of rectal examination, fecal occult blood testing, and flexible sigmoidoscopy among patients > 50 years was evaluated. The medical records of 200 patients (90 men and 110 women) were reviewed. Ninety-one rectal examinations, 26 fecal occult blood testing, and 30 flexible sigmoidoscopies were performed. There were 129 African-American (54 men and 75 women) and 52 white (26 men and 27 women) patients. Of the African-American patients, 57 underwent a rectal examination, 17 had fecal occult blood testing, and 26 underwent flexible sigmoidoscopy. Of the white patients, 24 had a rectal examination, 8 had fecal occult blood testing, and 12 underwent flexible sigmoidoscopy. These results demonstrate that resident physicians adhered poorly to colorectal cancer screening recommendations. There was no statistically significant difference in the screening of African-American and white patients. Increased efforts should be made to improve colorectal cancer screening practices by resident physicians.

Peptic-ulcer disease in the elderly.

Peptic-ulcer disease causes significant morbidity and mortality in the elderly. It frequently presents in an atypical manner and is associated with a high incidence of complications. The prevalence of Helicobacter pylori increases with age and can have an important role in the development of ulcers. Nonsteroidal anti-inflammatory drugs also contribute to the increased incidence of ulcers and the development of complications in the elderly. Although management of ulcer disease in the elderly is similar to that in the younger population, consideration must be given to the potential for increased incidence of side effects and medication interactions. When endoscopy and surgery are performed there should be an appreciation for the risks associated with concurrent illnesses that can accompany advanced age.