The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding.

PURPOSE: This study was designed to identify the short-term safety and efficacy of super-selective embolization for lower gastrointestinal bleeding and to examine the long-term durability. METHODS: Outcomes of patients who underwent super-selective embolization for lower gastrointestinal bleeding from January 1999 to September 2005 were identified retrospectively at a single institution. RESULTS: Seventy-five hospitalizations (71 patients) were identified. Mean age was 73 years. Short-term outcomes: this technique was successful in achieving immediate hemostasis in 73 of 75 cases identified (97 percent). Twelve patients (16 percent) rebled, eight required surgery, and four were successfully reembolized. Five patients (7 percent) developed postembolization ischemia: four required operations, and one was followed clinically. Long-term outcomes: 52 patients were followed for a mean of 32 months. Eight patients were readmitted for recurrent bleeding: four required surgeries, one was successfully reembolized, and the remaining three patients were followed clinically. CONCLUSIONS: This large series reaffirms the high success rate (97 percent) and relatively low acute ischemia risk (7 percent) of super-selective embolization for lower gastrointestinal bleeding. Furthermore, only 15 percent of patients ultimately required readmission for recurrent bleeding. It is our recommendation that super-selective embolization be used as the primary therapeutic modality in the treatment of angiogram positive lower gastrointestinal bleeding.

Anastomotic leaks: what is the best diagnostic imaging study?

PURPOSE: Postoperative anastomotic leaks are one of the most devastating consequences of colorectal surgery. Diagnostic imaging for upper gastrointestinal anastomotic leaks has been evaluated and reported on extensively. No study has compared the utility and effectiveness of CT scans and water-soluble enemas for the identification of postoperative lower gastrointestinal anastomotic leaks. The present study was designed to evaluate and compare these two common radiographic imaging modalities in detecting lower gastrointestinal anastomotic leaks. METHODS: A retrospective chart review was performed that identified 36 patients during a seven-year period who underwent reoperative surgery for a lower gastrointestinal anastomotic leak. Patient's imaging studies were classified as positive if extravasation of contrast material was demonstrated. When negative, a study was retrospectively reviewed in an attempt to identify findings suggestive of an anastomotic leak. RESULTS: There were 36 patients identified with a postoperative lower gastrointestinal leak requiring surgical intervention. There were 28 of 36 patients (78 percent) re-explored on the basis of a radiologic study demonstrating an anastomotic leak. A total of 27 CT scans were performed, of which 4 (14.8 percent) were considered positive for an anastomotic leak. On review of the remaining negative CT scans, nine (33.3 percent) were considered descriptive positive with a large amount of fluid or air in the peritoneal cavity but without obvious extravasation of contrast. Eighteen patients were evaluated with a water-soluble enema and 15 (83.3 percent) demonstrated extravasation of contrast material. In the 26 patients with a distal anastomotic leak, 17 water-soluble enemas were performed, with 15 (88 percent) demonstrating a leak. In contrast, only 2 of 17 (12 percent) CT scans were positive in this group of patients (P < 0.001). There were ten patients who initially had a CT scan followed by a water-soluble enema. Of these patients, eight of nine (88 percent) initially had a negative CT scan but were considered to be clinically suspicious of having an anastomotic leak and subsequently had a leak demonstrated on a water-soluble enema. CONCLUSIONS: Early intervention in patients who develop an anastomotic leak can be shown to improve the ultimate outcome, especially with respect to mortality. It is usually necessary to obtain objective tests of anastomotic integrity because of the nonspecificity of clinical signs. Our study supported the superiority of water-soluble enema to CT imaging in patients in whom both modalities were used. This difference was most pronounced for distal anastomotic leaks, whereas no radiologic imaging study proved effective in evaluating proximal anastomoses.

An in vitro model of early islet amyloid polypeptide (IAPP) fibrillogenesis using human IAPP-transgenic mouse islets.

The mechanisms underlying insufficient insulin secretion and loss of beta-cell mass in feline and human type 2 diabetes mellitus are incompletely understood. However, islet amyloid polypeptide (IAPP)-derived islet amyloidosis (IA) has been linked to increased rates of beta-cell apoptosis and, therefore, our goal was to develop an in vitro model of IAPP fibrillogenesis using isolated pancreatic islets from mice transgenic for human IAPP (hIAPP Tg mice). Islets from hIAPP Tg mice, from mice transgenic for non-amyloidogenic murine IAPP (mIAPP Tg mice), and from the FVB background strain were exposed to normal (5.5 mM) or high (28 mM) glucose conditions in cell culture for 8 days. On days 0 and 8, islets were collected for electron microscopy (EM). EM showed no abnormalities in the mIAPP Tg or FVB islets at either time point. On day 8, hIAPP Tg islets cultured at high glucose concentration formed extracellular IAPP-derived flocculent deposits. No significant differences in rates of apoptosis were found between groups. Our findings, therefore, show that in vitro culture of hIAPP Tg mouse islets under high glucose conditions produces a readily available and rapidly inducible model of IAPP-derived fibrillogenesis and enables the study of early phases of the molecular pathogenesis of IA.

Alcohol, tobacco, and drug use and the onset of type 2 diabetes among inner-city minority patients.

BACKGROUND: We examined the prevalence of alcohol, tobacco, and drug use and their relation to the age of onset of type 2 diabetes among inner-city minority diabetic patients who sought routine care at medical clinics in south central Los Angeles. METHODS: A cross-sectional study design was used to sample 392 diabetic patients. Consecutive patients from seven different primary care clinics were interviewed to determine their alcohol, tobacco, and drug use histories and the age of onset of diabetes. RESULTS: The study sample was 61% Hispanic and 64% female and had a mean age of 53 years. Seventy-one diabetic patients (18%) reported that they recently consumed alcohol. Sixty-nine patients (17%) reported smoking within 30 days of their interview. Thirty-eight diabetic patients reported a history of regular illicit drug use. Multiple regression analysis showed that diabetic patients who used alcohol, illicit drugs, or combined substances (alcohol and illicit drugs), but not tobacco alone, reported an earlier onset of type 2 diabetes. CONCLUSIONS: This hypothesis-generating study suggests that alcohol and illicit drugs, when used alone or in combination, might be associated with an earlier onset of type 2 diabetes. Additional research, however, is required to evaluate further these preliminary findings.

Alcohol consumption and compliance among inner-city minority patients with type 2 diabetes mellitus.

OBJECTIVE: To examine the relation between alcohol consumption and self-reported compliance with prescribed therapies for type 2 diabetes mellitus among underserved minority patients. DESIGN: Cross-sectional sampling of consecutive patients with diabetes was performed following routine visits to their primary care physicians. Interviewers measured compliance using the Summary of Diabetes Self-Care Questionnaire and alcohol use using the timeline followback method and the Alcohol Use Disorders Identification Test. SETTING: Seven inner-city medical clinics that provide primary care services to low-income residents of South Central Los Angeles, Calif. PARTICIPANTS: A total of 392 ethnic minority patients (61% Hispanic, 29% African American) with type 2 diabetes mellitus. MAIN OUTCOME MEASURES: Self-report compliance with prescribed diet, exercise, home glucose monitoring, medications, and outpatient follow-up. RESULTS: Drinking any alcohol-containing beverage within 30 days was associated with poorer adherence to prescribed dietary recommendations for the consumption of fiber (t = 2.4; P<.05), fat (t = 4.2; P<.01), sweets (t = 2.7; P<.01), and energy (calories) (t = 2.0; P<.05). Drinkers were also less likely to exercise for at least 20 minutes per day (t = 2.2; P<.05), comply with oral medication regimens (t = 4.6; P<.01), or attend outpatient follow-up visits (r = -0.11; P<.05). Alcohol use did not significantly alter compliance with home glucose monitoring, insulin use, or hemoglobin A(1c) levels, although there was a trend toward higher hemoglobin A(1c) levels among drinkers (11.0 vs 10.4). Multivariate analysis of the data demonstrates that when demographic characteristics, health care utilization, and other diabetes-related variables are held constant, the relation between alcohol use and dietary compliance remained significant. CONCLUSION: Alcohol consumption may be associated with poorer compliance with recommendations for some self-care behaviors among inner-city minority patients with diabetes. Arch Fam Med. 2000;9:964-970

Trophic-dynamic considerations in relating species diversity to ecosystem resilience.

Complexity in the networks of interactions among and between the living and abiotic components forming ecosystems confounds the ability of ecologists to predict the economic consequences of perturbations such as species deletions in nature. Such uncertainty hampers prudent decision making about where and when to invest most intensively in species conservation programmes. Demystifying ecosystem responses to biodiversity alterations may be best achieved through the study of the interactions allowing biotic communities to compensate internally for population changes in terms of contributing to ecosystem function, or their intrinsic functional redundancy. Because individual organisms are the biologically discrete working components of ecosystems and because environmental changes are perceived at the scale of the individual, a mechanistic understanding of functional redundancy will hinge upon understanding how individuals' behaviours influence population dynamics in the complex community setting. Here, I use analytical and graphical modelling to construct a conceptual framework for predicting the conditions under which varying degrees of interspecific functional redundancy can be found in dynamic ecosystems. The framework is founded on principles related to food web successional theory, which provides some evolutionary insights for mechanistically linking functional roles of discrete, interacting organisms with the dynamics of ecosystems because energy is the currency both for ecological fitness and for food web commerce. Net productivity is considered the most contextually relevant ecosystem process variable because of its socioeconomic significance and because it ultimately subsumes all biological processes and interactions. Redundancy relative to productivity is suggested to manifest most directly as compensatory niche shifts among adaptive foragers in exploitation ecosystems, facilitating coexistence and enhancing ecosystem recovery after disturbances which alter species' relative abundances, such as extinctions. The framework further explicates how resource scarcity and environmental stochasticity may constitute 'ecosystem legacies' influencing the emergence of redundancy by shaping the background conditions for foraging behaviour evolution and, consequently, the prevalence of compensatory interactions. Because it generates experimentally testable predictions for a priori hypothesis testing about when and where varying degrees of functional redundancy are likely to be found in food webs, the framework may be useful for advancing toward the reliable knowledge of biodiversity and ecosystem function relations necessary for prudent prioritization of conservation programmes. The theory presented here introduces explanation of how increasing diversity can have a negative influence on ecosystem sustainability by altering the environment for biotic interactions and thereby changing functional compensability among biota--under particular conditions.

Integrating osteopathic training into family practice residencies.

BACKGROUND AND OBJECTIVES: Since the mid-1980s, the number of osteopathic graduates has increased, and the number of osteopathic hospitals has decreased. This has led to an increasing number of osteopathic students seeking training in Accreditation Council for Graduate Medical Education (ACGME) family practice residency programs. In response to these developments and to a declining pool of allopathic applicants in the early 1990s, at least 35 ACGME programs have completed the American Osteopathic Association (AOA) accreditation process as approved internship sites. This article describes 1) the rationale for becoming accredited, 2) the AOA accreditation process, 3) a model osteopathic curriculum, 4) potential difficulties, 5) issues to consider in approaching a decision to become AOA accredited, and 6) future trends in osteopathic graduate medical education.

Isolated right-ventricular hypertrophy associated with severe pulmonary vascular apolipoprotein A1-derived amyloidosis in a dog.

A 12-year-old dachshund was referred for respiratory distress, coughing, and weight loss. Cyanosis, dyspnea, tachypnea, and harsh lung sounds were noted on physical examination. Polycythemia with an increased number of nucleated red blood cells; right atrial enlargement; severe interstitial-to-alveolar pattern in all lung fields; and peripheral, echogenic, pulmonary masses were observed. Cytological examination of pulmonary aspirates indicated possible pulmonary carcinoma. The dog was euthanized at the owner's request. Isolated right-ventricular hypertrophy and pulmonary arteriopathy with amyloid deposits of apolipoprotein A1 were identified upon necropsy and histopathology. Pulmonary vascular amyloidosis should be considered in the differential diagnoses of respiratory distress in aged dogs.

Quantitative immunohistochemical analysis of islet amyloid polypeptide (IAPP) in normal, impaired glucose tolerant, and diabetic cats.

Islet amyloid polypeptide (IAPP, "amylin") has been proposed as having important roles in the pathogenesis of type 2 diabetes mellitus via its biological activity and by forming islet amyloid. The domestic cat develops a type of diabetes that closely resembles type 2 diabetes in humans, including the frequent formation of islet amyloid deposits in the impaired glucose tolerant (IGT) and diabetic state. With the aid of computerized image analysis and immunohistochemistry, we examined the IAPP and insulin content in pancreatic islets of normal, IGT and diabetic cats. IAPP immunoreactivity in beta cells from IGT cats was significantly stronger (p < 0.01) as compared with cells from normal cats, while the insulin labelling strength was unchanged. Overtly diabetic cats were usually almost devoid of beta cells. As in humans, cellular IAPP but not IAPP in islet amyloid deposits was labelled by the newly developed monoclonal antibody to IAPP 4A5, thus providing further evidence that IAPP is modified by a yet unknown mechanism during the amyloidogenic process. The study provides evidence that an increased beta cell storage of IAPP independent of insulin may be an important factor in the early phase of the development of islet amyloid in this form of diabetes.

Systemic AA amyloidosis in captive cheetahs (Acinonyx jubatus).

Ongoing disease surveillance of necropsied captive cheetahs (Acinonyx jubatus) (n = 141) revealed a high prevalence of renal amyloidosis (n = 54 [38%]; age 1 to 16 years). The prevalence increased from 20% in pre- 1990 necropsies to 70% of cheetahs necropsied in 1995. In 74% of the cheetahs with amyloidosis, renal failure was determined to be the sole or partial cause of death. Papillary necrosis was seen only in affected cheetahs and involved 25% of these animals. Amyloid was present predominantly in the medullary interstitium, with minimal glomerular involvement. The amyloid deposits were immunohistochemically identified as AA type using antisera to both human and canine protein AA. A high percentage (52%) of animals with renal amyloid also had subsinusoidal hepatic AA amyloid deposits. Inflammatory diseases were identified in 100% of affected cheetahs. The most common inflammatory disease was chronic lymphoplasmacytic gastritis. The prevalence and severity of gastritis was higher in cheetahs with amyloidosis, and the prevalence of severe gastritis increased from 16% to 43%, coinciding with the increase in prevalence of amyloidosis. These findings suggest that cheetahs have a high prevalence of systemic amyloidosis in response to inflammation and that renal amyloidosis is an increasingly significant cause of morbidity and mortality in captive cheetah populations. Factors of potential importance in the apparent high prevalence of AA amyloidosis in cheetahs are currently being investigated in our laboratories.

The reading habits of family practice residents.

BACKGROUND AND OBJECTIVES: Little is known about the reading habits of family practice residents. This study describes the reading practices of family practice residents, including how much time they spend reading and what information sources they use, identifies factors that may be used by educators to stimulate resident reading, and identifies factors that may inhibit or discourage reading. METHODS: A questionnaire about reading habits was mailed to 613 randomly selected resident members of the American Academy of Family Physicians in March 1994. RESULTS: Of 613 questionnaires sent, 314 (51%) were completed and returned. Participants reported reading an average of 3.7 hours per week and were most often motivated to read to obtain information related to clinical cases or to prepare for an upcoming presentation. Pocket manuals were the most frequently read and original scientific research the least frequently read sources of medical information. Fatigue and family responsibilities were the factors most important in preventing reading. Year in residency, moonlighting hours, age, gender, or household size were not associated with reported reading time. CONCLUSIONS: Clinical cases and upcoming presentations may be the best motivators of resident reading. Training programs need to continue to develop strategies to minimize resident fatigue, which may lead to increased reading among trainees. The importance of original scientific research articles during residency training is unclear.

Osteoporotic vertebral fractures in postmenopausal women.

Back pain is a common symptom in postmenopausal women. As in younger age groups, most cases of back pain in postmenopausal women do not represent serious disease and resolve spontaneously within four weeks. However, acute back pain in postmenopausal women may be caused by vertebral fracture, and "red flags" in the history and physical examination can help clinicians decide on the appropriate work-up. When findings suggest vertebral fracture, anteroposterior and lateral radiographs of the thoracolumbar spine should be obtained. The diagnosis of existing vertebral fractures is critical because the probability of sustaining new spine and hip fractures is increased in women with one vertebral fracture, and the presence of multiple fractures puts the patient at risk for chronic debilitation. Acute fractures should be treated supportively, and a further work-up should be performed to assess the degree of osteoporosis and to exclude secondary causes. Evaluation of bone mineral density is a helpful guide to further management. Treatment may include calcium and vitamin D, hormone replacement therapy, bisphosphonates and/or calcitonin.