Single-Day Low-Residue Diet Prior to Colonoscopy Demonstrates Improved Bowel Preparation Quality and Patient Tolerance over Clear Liquid Diet: A Randomized, Single-Blinded, Dual-Center Trial.

BACKGROUND AND AIMS: Patients often refer to bowel preparation and associated dietary restrictions as the greatest deterrents to having a colonoscopy completed or performed. Large studies comparing a low-residue diet (LRD) and a clear liquid diet (CLD) are still limited. The aim of this study is to compare LRD and CLD with regard to bowel preparation quality, tolerance, and satisfaction among a diverse patient population. METHODS: This study is a dual-center, randomized, single-blinded, prospective trial involving adult patients undergoing outpatient colonoscopy at the University of California Irvine Medical Center and an affiliated Veterans Administration hospital. Patients were randomized to consume either a CLD or a planned LRD for the full day prior to colonoscopy. Both groups consumed 4L split-dosed PEG-ELS. The adequacy of bowel preparation was evaluated using the Boston Bowel Preparation Score (BBPS). Adequate preparation was defined as a BBPS ≥ 6 with no individual segment less than a score of 2. Hunger and fatigue pre - and post-procedure were graded on a ten-point scale. Nausea, vomiting, bloating, abdominal cramping, overall discomfort, satisfaction with the diet, willingness to repeat the same preparation and overall experience were assessed. RESULTS: A total of 195 subjects who underwent colonoscopy from October 2014 to October 2017 were included. The mean BBPS for the LRD and CLD groups was 8.38 and 7.93, respectively (p = 0.1). There was a significantly higher number of adequate preparations in the LRD group compared to CLD (p = 0.05). Evening hunger scores just before starting the bowel preparation were significantly lower in the LRD than the CLD group, 2.81 versus 5.97, respectively (p = 0.006). Subjects in the LRD group showed significantly less nausea (p = 0.047) and bloating (p = 0.04). Symptom scores for vomiting, abdominal cramping, and overall discomfort were similar between the groups. Satisfaction with diet was significantly higher in the LRD group than CLD, 72% versus 37.66%, respectively (p < 0.001). The overall colonoscopy experience and the satisfaction with the preparation itself were also better reported in the LRD group (p < 0.001 and p = 0.002, respectively). CONCLUSIONS: This study, which included a diverse group of patients, demonstrated that patients using a LRD before colonoscopy achieve a bowel preparation quality that is superior to patients on a CLD restriction. This study shows that a low-residue diet improves patient satisfaction and results in significantly better tolerability of bowel preparation. As a less restrictive dietary regimen, the low-residue diet may help improve patient participation in colorectal cancer screening programs.

Low-residue versus clear liquid diet before colonoscopy: a meta-analysis of randomized, controlled trials.

BACKGROUND AND AIMS: Colonoscopy is extremely important for the identification and removal of precancerous polyps. Bowel preparation before colonoscopy is essential for adequate visualization. Traditionally, patients have been instructed to consume only clear liquids the day before a colonoscopy. However, recent studies have suggested using a low-residue diet, with varying results. We evaluated the outcomes of patients undergoing colonoscopy who consumed a clear liquid diet (CLD) versus low-residue diet (LRD) on the day before colonoscopy by a meta-analysis. METHODS: Scopus, PubMed/MEDLINE, Cochrane databases, and CINAHL were searched (February 2015). Studies involving adult patients undergoing colonoscopy examination and comparing LRD with CLD on the day before colonoscopy were included. The analysis was conducted by using the Mantel-Haenszel or DerSimonian and Laird models with the odds ratio (OR) to assess adequate bowel preparations, tolerability, willingness to repeat diet and preparation, and adverse effects. RESULTS: Nine studies (1686 patients) were included. Patients consuming an LRD compared with a CLD demonstrated significantly higher odds of tolerability (OR 1.92; 95% CI, 1.36-2.70; P < .01) and willingness to repeat preparation (OR 1.86; 95% CI, 1.34-2.59; P < .01) with no differences in adequate bowel preparations (OR 1.21; 95% CI, 0.64-2.28; P = .58) or adverse effects (OR 0.88; 95% CI, 0.58-1.35; P = .57). CONCLUSION: An LRD before colonoscopy resulted in improved tolerability by patients and willingness to repeat preparation with no differences in preparation quality and adverse effects.

Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials.

BACKGROUND & AIMS: No therapy has been proven to prevent the recurrence of diverticulitis. Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease, and there is preliminary evidence that it might be effective for diverticular disease. We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3, randomized, double-blind, placebo-controlled, multicenter trials (identical confirmatory trials were conducted for regulatory reasons). METHODS: We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 (PREVENT1) and 592 (PREVENT2) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery. Patients received mesalamine (1.2 g, 2.4 g, or 4.8 g) or placebo once daily for 104 weeks. The primary end point was the proportion of recurrence-free patients at week 104. Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening (>5 mm) and/or fat stranding consistent with diverticulitis. For a portion of the study, recurrence also required the presence of abdominal pain and an increase in white blood cells. RESULTS: Mesalamine did not reduce the rate of diverticulitis recurrence at week 104. Among patients in PREVENT1, 53%-63% did not have disease recurrence, compared with 65% of those given placebo. Among patients in PREVENT2, 59%-69% of patients did not have disease recurrence, compared with 68% of those given placebo. Mesalamine did not reduce time to recurrence, and the proportions of patients requiring surgery were comparable among treatment groups. No new adverse events were identified with mesalamine administration. CONCLUSIONS: Mesalamine was not superior to placebo in preventing recurrent diverticulitis. Mesalamine is not recommended for this indication. ClinicalTrials.gov ID: NCT00545740 and NCT00545103.

A randomized, placebo-controlled trial of lubiprostone for opioid-induced constipation in chronic noncancer pain.

OBJECTIVES: This multicenter, phase 3 trial evaluated oral lubiprostone for constipation associated with non-methadone opioids in patients with chronic noncancer-related pain. METHODS: Adults with opioid-induced constipation (OIC; <3 spontaneous bowel movements [SBMs] per week) were randomized 1:1 to double-blind lubiprostone 24 µg or placebo twice daily for 12 weeks. The primary end point was the overall SBM response rate. Responders had at least moderate response (≥1 SBM improvement over baseline frequency) in all treatment weeks with available observed data, as well as full response (≥3 SBMs per week) for at least 9 of the 12 treatment weeks. RESULTS: In total, 431 patients were randomized; 212 each received lubiprostone and placebo, and 7 were not treated. Overall, the SBM response rate was significantly higher for patients treated with lubiprostone vs. placebo (27.1 vs. 18.9%, respectively; P=0.030). Overall mean change from baseline in SBM frequency was significantly greater with lubiprostone vs. placebo (3.2 vs. 2.4, respectively; P=0.001). The median time to first SBM was significantly shorter with lubiprostone vs. placebo (23.5 vs. 37.7 h, respectively; P=0.004). Compared with placebo, the patients treated with lubiprostone exhibited significant improvements in straining (P=0.004), stool consistency (P<0.001), and constipation severity (P=0.010). No significant differences were observed in quality-of-life measures or the use of rescue medication; however, the percentage of patients who used rescue medication was consistently lower in the lubiprostone group than in the placebo group at months 1 (34.9 vs. 37.7%), 2 (23.4 vs. 26.6%), and 3 (20.5 vs. 22.0%). Adverse events (AEs) >5% were diarrhea, nausea, vomiting, and abdominal pain (lubiprostone: 11.3, 9.9, 4.2, and 7.1%, respectively; placebo, 3.8, 4.7, 5.2, and 0%, respectively). None of the serious AEs (lubiprostone, 3.3%; placebo, 2.8%) were related to lubiprostone. CONCLUSIONS: Lubiprostone significantly improved symptoms of OIC and was well tolerated in patients with chronic noncancer pain.

Opioid induced bowel disease: a twenty-first century physicians' dilemma. Considering pathophysiology and treatment strategies.

The treatment of cancer-associated pain as well as chronic non-cancer-related pain (CNCP) is an increasingly relevant topic in medicine. However, it has long been recognized that opiates can adversely affect many organ systems, most notably the gastrointestinal system. These are referred to as the spectrum of "opioid-induced bowel dysfunction" (OBD) or what we will refer to as "opioid-induced bowel disease" (OIBD) which include constipation, nausea, vomiting, delayed gastric emptying, and gastro-esophageal reflux disease (GERD), and a newer entity known as narcotic bowel syndrome (NBS). Opioid analgesics are increasingly being used for the treatment of cancer pain, non-cancer-associated pain, and postoperative pain. As we achieve our goals towards pain control, we need to be cognizant of and competent in how to prevent and treat OIBD. The basis is due in part to µ-receptor activation, decreasing the peristaltic contraction and leading to sequelae of OIBD. Treatment beyond lifestyle interventional strategy will employ laxatives and stool softeners. However, studies performed while patients were already using laxativies and stool softeners have elicited the necessity of peripherally acting agents such as methylnaltrexone (MNTX) and alvimopan. Patients responded dramatically to both medications, but these studies were limited to patients that were deemed to have advanced illness. Lubiprostone, while different in its mechanism of action from MNTX and alvimopan, has proven effective and should be considered for use in OIBD. Further investigational research will promulgate more information and allow for better and more efficient treatment options for OIBD.

African-Americans, Hispanic Americans, and non-Hispanic whites without GERD or reflux symptoms have equivalent 24-h pH esophageal acid exposure.

BACKGROUND: Ambulatory esophageal pH monitoring is, currently, the recommended diagnostic exam for gastroesophageal reflux disease. Data are currently available for African-American (AA) and non-Hispanic white (nHw) volunteers among United States ethnic groups. The purpose of this study was to obtain normal values of 24-h esophageal pH by monitoring healthy adult Hispanic American (HA) volunteers and to compare these with values obtained from healthy AA and nHw volunteers to determine if ethnic variation exists in 24-h esophageal pH. METHODS: 24-h Dual esophageal pH monitoring was performed for healthy AA, HA, and nHw. Values for total number of reflux episodes, episodes longer than 5 min, total reflux time, and longest reflux episode in the proximal and/or distal esophagus were obtained for all groups. Differences between groups were considered significant if p<0.05. RESULTS: One-hundred and thirty-six subjects volunteered and completed 24-h pH testing. Fifty-three were AA, 25 HA, and 58 nHw, with males accounting for 52, 47, and 47%, respectively, of each group. AA were older than nHw only and nHw had a lower body mass index than both AA and HA. Shorter study duration was observed for HA than for AA and nHw. No difference was observed between ethnic groups for any measured pH data in the proximal or distal esophagus. CONCLUSIONS: No difference exists in values obtained during esophageal pH monitoring among healthy AA, HA, and nHw. This indicates that currently accepted normal values of ambulatory esophageal pH monitoring can be used for all major United States ethnic groups without compromising diagnostic accuracy.

Ultrasound marking by gastroenterologists prior to percutaneous liver biopsy removes the need for a separate radiological evaluation.

BACKGROUND/AIM: Ultrasound marking by radiologists prior to percutaneous liver biopsy (PLB) results in biopsy site adjustment, decreased pain related complications and improved tissue yield. Minimal data exists on the impact of ultrasound marking by gastroenterologists on these parameters. The study aim was to evaluate whether ultrasound marking by gastroenterologists results in improved PLB tissue yield, fewer needle passes and decreased biopsy failure rates compared to blind biopsy, eliminating the need for a separate radiological evaluation. METHODOLOGY: All PLB performed by gastroenterologists from June 1999 to February 2003 at the University of Florida College of Medicine, Jacksonville, were reviewed retrospectively. Data collected included ultrasound marked or blind PLB, demographics, indication, number of passes performed, and specimen length, if obtained. RESULTS: Four hundred and eighty PLB were included: 328 performed with ultrasound marking and 152 blind. Ultrasound marking by gastroenterologists prior to PLB resulted in fewer passes and longer specimens as well as a decreased failure rate in ultrasound marked compared to blind PLB. CONCLUSIONS: Ultrasound marking by gastroenterologists prior to PLB provided significantly larger tissue samples, fewer needle passes and a decreased biopsy failure rate compared to blind PLB. This removes the need for a separate radiological evaluation on the procedure day.

Split-dosed MiraLAX/Gatorade is an effective, safe, and tolerable option for bowel preparation in low-risk patients: a randomized controlled study.

OBJECTIVES: MiraLAX with Gatorade is a low-volume bowel preparation regimen that has been used widely in community practice and is anecdotally better tolerated than Golytely. Despite its widespread use, there are little data on the efficacy and tolerability of this solution and no safety data in the literature. The primary aim of this study was to compare the efficacy, safety, and tolerability of single-dosed and split-dosed regimens of MiraLAX/Gatorade with Golytely for bowel preparation before colonoscopy. METHODS: Adults presenting for outpatient colonoscopy were screened for enrollment into this single-blinded randomized controlled trial. Patients with severe cardiac or renal disease and patients with electrolyte abnormalities were excluded. Subjects were randomized into four groups: 4 l Golytely single-dosed (Go-Si), 4 l Golytely split-dosed (Go-Sp), 238 g MiraLAX in 64 oz of Gatorade single-dosed (Mlax-Si), and MiraLAX/Gatorade split-dosed (Mlax-Sp) groups. Laboratory data including complete blood count, comprehensive metabolic panel, and osmolality were collected before the day of bowel preparation and just before the start of colonoscopy. Subjects completed a survey assessing taste and tolerability of the solution. Colonoscopies were recorded using video recording software and de-identified. Colonoscopy videos were evaluated for efficacy of cleansing by two blinded endoscopists. Two validated bowel preparation scales were used to assess bowel cleansing: the Boston Bowel Preparation Scale (BBPS; 0-9 best) and Ottawa Scale (0-14 worst). RESULTS: A total of 222 patients were evaluated in this study (86.2% male, mean age 59.4). Of these, 57 subjects were randomized to the Go-Si group, 51 to Go-Sp group, 60 to Mlax-Si group, and 54 to Mlax-Sp group. There was no significant difference in age, gender, or timing of colonoscopy between the groups (P>0.05). Mean BBPS scores were: Go-Si=6.07, Go-Sp=8.33, Mlax-Si=6.62, and Mlax-Sp=8.01. Mean Ottawa score for the groups were: Go-Si group=6.77, Go-Sp=4.12, Mlax-Si=6.25, and Mlax-Sp=4.8. Go-Sp resulted in significantly better cleansing than Go-Si (P<0.01). Mlax-Sp resulted in significantly better cleansing than Mlax-Si (P<0.01). There was no significant difference in BBPS between Go-Sp and Mlax-Sp. There were no clinically significant electrolyte changes from baseline in any subject in any group after bowel prep (P>0.05). Subjects rated the taste and overall experience of Mlax/Gatorade preparation better than Golytely (P<0.01). In all, 96.8% of Mlax/Gatorade subjects were willing to repeat the same preparation vs. 75% for Golytely subjects (P<0.01). CONCLUSIONS: Split-dosed MiraLAX/Gatorade was an effective, safe, and tolerable option for bowel preparation before colonoscopy in the low-risk patients in this study. MiraLAX/Gatorade appears to be more tolerable than Golytely as a bowel cleansing regimen and was the preferred agent by the patients in this study.

African Americans with Barrett's esophagus are less likely to have dysplasia at biopsy.

BACKGROUND: Barrett's Esophagus (BE) is a pre-malignant condition. Limited data on BE dysplasia prevalence exists among United States ethnic groups. AIM: The purpose of this study was to determine if the frequency of BE with dysplasia varies among the major ethnic groups presenting to our institution. METHODS: The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to August 2007. Histologic BE was diagnosed if salmon colored esophageal mucosa was endoscopically seen at least 1 cm above the top of the gastric folds and biopsy revealed intestinal metaplasia with Alcian blue-containing goblet cells. Demographic data collected for all included: age at diagnosis, ethnicity, sex, previous history of esophageal reflux, atypical manifestations (chronic cough, aspiration), endoscopic length of BE, presence or absence of hiatal hernia, esophageal stricture or ulcer, and presence or absence of dysplasia. RESULTS: Salmon colored esophageal mucosa was observed in 405 of 7,308 patients (5.5%) and histologically confirmed in 115 of 405 patients (28%) reflecting an overall prevalence of BE of 115/7308 (1.6%) in this cohort. Ethnic distribution of histologic BE patients was as follows: 95 (83%) non-Hispanic white (nHw), 16 (14%) African American (AA) and 4 (3%) other. Long segment BE (LSBE) and any form of dysplasia was observed less frequently in AA than nHw (LSBE: 12% vs. 26% and dysplasia: 0% vs. 7%). CONCLUSIONS: LSBE and dysplasia are less frequent in AA than nHw. Studies in AA with BE may illustrate factors limiting dysplasia and LSBE risk.

Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication.

Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 - 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 - 480). Results: Median operative time was 144 minutes (90 - 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 - 312). Median follow up was 157 months (6 - 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.

Decreasing hospitalization and in-hospital mortality related to cholangitis in the United States.

OBJECTIVES: The aim of this study was to determine trends in hospitalization rates and in-hospital mortality of cholangitis and also determine predictive factors of in-hospital mortality. METHODS: The Nationwide Inpatient Sample database was utilized for inpatient data analysis from 1988 to 2006. Patients with primary cholangitis International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) discharge diagnosis were included. Age-adjusted procedure rates for endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement and sphincterotomy were also analyzed. Analysis of variance was used to evaluate trends, and linear Poisson multivariate regression model was used to control for variations in age, sex, time of diagnosis, and ethnicity. Logistic regression analysis was performed to determine predictive factors of in-hospital mortality. RESULTS: The age-adjusted hospitalization rate of cholangitis decreased 24.8% from 2.34 per 100,000 in 1988 to 1.76 per 100,000 in 2006 (P < 0.01). The age-adjusted in-hospital mortality of cholangitis increased 9.2% from 165.0 to 181.6 per 100,000 from 1988 to 1998 (P < 0.01), and then declined 73% to 48.9 per 100,000 in 2006 (P < 0.01). The age-adjusted procedure rates for ERCP with biliary stenting increased from 0.55 to 15.23 per 100,000 from 1988 to 2006 (P < 0.01), as did the age-adjusted rates for ERCP with sphincterotomy from 1.06 to 35.64 per 100,000 (P < 0.01). CONCLUSIONS: The hospitalization rate of cholangitis has been declining over the past 2 decades. The overall trend in mortality peaked in 1998 and has shown a subsequent decline that may in part be related to increased utilization of endoscopic biliary decompression.

Changing pattern of esophageal cancer incidence in New Mexico: a 30-year evaluation.

BACKGROUND AND AIM: The incidence of esophageal adenocarcinoma has increased over the last 30 years, especially in non-Hispanic whites (nHw). Recent work indicates an increase in Hispanic Americans (HA). It is important to understand the effect of ethnicity on cancer occurrence over a prolonged interval. METHODS: We searched the New Mexico Tumor Registry for all cases of esophageal cancer from 1 January 1973 to 31 December 2002. Inclusion criteria were histologic diagnosis of adenocarcinoma or squamous cell carcinoma, ethnicity and gender. Incidence rates for both were compared among ethnic groups in 5-year intervals. RESULTS: Nine hundred eighty-eight patients met the criteria. Esophageal adenocarcinoma incidence rates/100,000 population increased significantly over 30 years; 1973-1977, 0.4 cases; 1978-1982, 0.4 cases; 1983-1987, 0.6 cases; 1988-1992, 1.2 cases, 1993-1997, 1.6 cases and 1998-2002, 2.2 cases; P < 0.001. Squamous cell carcinoma incidence rates remained unchanged during the interval. In nHw and HA, adenocarcinoma incidence rates increased significantly during the study period. In all minority groups, squamous cell carcinoma remained the major type. CONCLUSIONS: Esophageal adenocarcinoma incidence among nHw and HA increased from 1973 to 2002 in New Mexico. Squamous cell carcinoma remains predominant in minorities. Ethnicity may influence the histology or indicate an increased risk for certain types of esophageal cancer.

Overuse of acid suppression therapy in hospitalized patients.

BACKGROUND: Acid suppression therapy (AST) is one of the most commonly prescribed classes of medications in hospitalized patients. Multiple studies have shown that AST is overused during inpatient admissions. However, minimal data is available regarding the frequency and patient characteristics of those discharged on unnecessary AST. The aims of the study were to examine administration of AST on admission, to characterize the patient population discharged on unnecessary AST and to determine predictive factors for inappropriate administration of AST in hospitalized patients. METHODS: A retrospective chart review of randomly selected patients admitted to the general medicine service at University of Florida Health Science Center/Jacksonville from August to October 2006 for appropriateness of AST was done. The admitting diagnosis, indications for starting AST, type of AST used, and discharge on these medications was recorded on a case by case basis. RESULTS: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge. CONCLUSION: AST is overused in hospitalized patients. This primarily occurred in low risk patients and was compounded by continuation at discharge. This significantly increases cost to the health care system and the risk of drug interactions.

Nationwide trends in the utilization of multivessel percutaneous coronary intervention (MVPCI) in the United States across different gender and ethnicities.

BACKGROUND: To evaluate nationwide trends in the utilization of Multivessel Percutaneous Coronary Intervention (MVPCI) in the past compared to recent years using a large database from 1988 to 2004. METHOD: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted rate for multivessel percutaneous coronary intervention (MVPCI) from 1988 to 2004. Specific ICD-9-CM codes for MVPCI were used to compile the data. Patient demographic data were also analyzed from the database. RESULTS: According to the NIS database, MVPCI was performed in 241,319 patients from 1988 to 2004. Males underwent MVPCI twice as many as compared to females (male: 67.87%, female 32.13%). The mean age for these patients was 64.89 +/- 11.84 years old. From 1988, the age-adjusted rate for MVPCI gradually increased to more than three times in 1998 [(6.62 per 100,000 (95%CI = 5.92-7.33) in 1988 to 23.92 per 100,000 (95%CI = 21.62-26.22, P < 0.01) in 1998] and accelerated to more than 6 times that of 1988 at the end of the study in 2004 (41.50 per 100,000 (95%CI = 37.84-45.16). In recent years, this trend was similar for both genders and ethnicities. CONCLUSION: The utilization of MVPCI has increased six times from 1988 to 2004, with acceleration in recent years. The cause of this acceleration is most likely related to the advancement in the percutaneous coronary interventional techniques.

Declining hospitalization rate of esophageal variceal bleeding in the United States.

BACKGROUND & AIMS: In recent years, there have been many advances in the primary and secondary prophylaxis of variceal bleeding. The aim of this study was to evaluate nationwide trends in the hospitalization rate of bleeding esophageal varices in the advent of these new modalities. In addition, our aims were to study the incidence trends of nonbleeding esophageal varices over the past 2 decades while studying hospitalization rates for cirrhosis over the same study period. METHODS: The Nationwide Inpatient Sample database was used for inpatient data analysis (1988-2002) and the State Ambulatory Surgery Database was used for outpatient analysis. Patients discharged with International Classification of Diseases, ninth revision, Clinical Modification discharge diagnoses related to esophageal varices were included. RESULTS: The hospitalization rate of bleeding varices increased 13.7% from 10.9 per 100,000 in the 1988 to 1990 period to 12.4 per 100,000 in the 1994 to 1996 period (P < .01), and then decreased 14.5% to 10.6 per 100,000 in the 2000 to 2002 period (P < .01). In-hospital nonbleeding varices increased 55% from 6.0 to 9.3 per 100,000 from the 1988 to 1990 period to the 2000 to 2002 period (P < .01). Outpatient nonbleeding esophageal varices increased 20% from 5.5 to 6.6 per 100,000 from 1997 to 2003. CONCLUSIONS: The hospitalization rate for bleeding esophageal varices has been on the decline in recent years and may be a reflection of the advances in primary and secondary prophylaxis. The incidence rate of nonbleeding esophageal varices is increasing and likely is owing to the increasing burden of portal hypertensive liver disease in the nation.

Increased prevalence of infectious endocarditis in patients with type II diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus (DM) are at increased risk of infection. However, there are controversial reports about DM association with infectious endocarditis (IE). We evaluated the occurrence of IE in DM patients compared to a matched control. METHOD: Treatment files of inpatients' admission that contained discharge diagnosis (ICD-9 codes) from Veterans Health Administration hospitals were used for this study. ICD-9 codes for DM (n=293,124) and a control group with ICD-9 codes for hypertension without DM (n=552,623) were utilized for comparison. The prevalence of IE was studied using ICD-9 codes for IE. Multivariate analysis was performed adjusting for chronic and acute renal failure and aortic and mitral valve disease. Continuous variables were analyzed by unpaired t tests. Binary variables were analyzed using the chi-square test and Fisher's Exact Tests. RESULTS: IE was present in 1340 (0.5%) DM patients versus 1412 (0.3%) patients from the control group (relative increase of 40%). Using multivariate analysis adjusting for renal failure and valvular abnormalities, DM remained independently associated with IE (odds ratio=1.9; 95% confidence interval=1.8-2.1; P<.0001). CONCLUSION: Patients with type II DM have significantly higher prevalence of IE independent of renal failure or valvular abnormalities consistent with increased vulnerability of DM patients for infections.

Cosegregation of gastrointestinal ulcers and schizophrenia in a large national inpatient discharge database: revisiting the "brain-gut axis" hypothesis in ulcer pathogenesis.

The lifetime prevalence of duodenal ulcer in the United States is 8 to 10%, whereas another 1% of the population is affected by gastric ulcer. Both central and peripheral dopamine pathways may influence ulcer pathogenesis. Dopamine agonists prevent whereas antagonists augment stress- and chemically induced gastrointestinal ulcers in preclinical models. The dopaminergic neurotoxin 1-methyl-4-phenyl-1,2,36-tetrahydropyridine (MPTP) depletes central dopamine and induces lesions in the substantia nigra, and, if given in high doses, MPTP induces a Parkinson disease-like syndrome and gastric ulcers. Because schizophrenia is attributed, in part, to an overactive dopaminergic system, persons with schizophrenia may display a reduced susceptibility toward gastrointestinal ulcers. A case-control study was conducted in patients represented in the 2002 National Inpatient Sample, the largest all-payer inpatient care database in the United States, consisting of 5 to 8 million inpatient hospital stays per year, which approximates a 20% sample of community hospitals. A significant association was observed between schizophrenia and diminished risk for duodenal (odds ratio [OR] 0.55; 95% confidence interval [CI] 0.45-0.67) and gastric (OR 0.54; 95% CI 0.46-0.63) (p < .01) ulcers but not for gastrojejunal ulcers (OR 0.44; 95% CI 0.16-1.20) (p = .11). Potential confounders such as age, gender, race, tobacco or alcohol dependence, and Helicobacter pylori infection were controlled in multivariate analyses. This observational study in a large sample of patients in community hospitals suggests that schizophrenia and attendant neurobiologic mechanisms (eg, variability in dopamine pathways) may act in concert to modify the composite risk for gastrointestinal ulcers. Dopamine pathways warrant further prospective research as new potential drug targets in ulcer disease.

The frequency of histologically confirmed Barrett's esophagus varies by the combination of ethnicity and gender.

BACKGROUND: Barrett's esophagus (BE) is the primary risk factor for esophageal adenocarcinoma (EAC). Limited data exists regarding the frequency of histologically confirmed BE by both gender and ethnicity in the United States. The study aim was to determine whether the frequency of histologically confirmed BE varies by ethnicity and gender. METHODS: The University of Florida-Jacksonville endoscopy database was reviewed for all cases of salmon colored esophageal mucosa from September 2002 to August 2007. Histologic BE was diagnosed only if salmon colored esophageal mucosa was seen endoscopically and biopsy confirmed intestinal metaplasia with goblet cells. Data collected included: age at diagnosis, self-reported ethnicity [non-Hispanic white (nHw) or African American (AA)], gender, procedure indication, gastroesophageal reflux disease (GERD) history, atypical manifestations, cigarette smoking, alcohol use, proton pump inhibitor (PPI) use, BE endoscopic length, absence/presence of hiatal hernia, stricture or ulcer, and absence/presence/grade of dysplasia. RESULTS: Salmon colored esophageal mucosa was identified in 391/7,308 patients, distributed ethnically as 306 nHw and 85 AA. Histologic BE was confirmed in 111/391 patients with ethnic distribution of: 95 nHw and 16 AA. Histologically confirmed BE frequency varied both by gender and ethnicity with nHw males having the highest (42.3%) and AA females the lowest (12.3%). Histologically confirmed BE frequency differed significantly between nHw males and nHw/AA females only (P<0.005). CONCLUSIONS: Histologically confirmed BE frequency varies by ethnicity and gender with nHw males having the highest frequency/risk and AA females the lowest. Investigation to improve understanding of the impact of race and gender in BE formation should be performed.

Epidemiology of hepatitis C virus (HCV) infection.

Hepatitis C virus remains a large health care burden to the world. Incidence rates across the world fluctuate and are difficult to calculate given the asymptomatic, often latent nature of the disease prior to clinical presentation. Prevalence rates across the world have changed as well with more countries aware of transfusion-related hepatitis C and more and more evidence supporting intravenous drug use as the leading risk factor of spread of the virus. This article reviews current hepatitis C virus prevalence and genotype data and examines the different risk factors associated with the virus.

National Trends and In-Hospital Outcomes of Adult Patients With Inflammatory Bowel Disease Receiving Parenteral Nutrition Support.

BACKGROUND: Patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are susceptible to protein-calorie malnutrition secondary to decreased oral intake, malabsorption, and increased metabolic expenditure. In this study, we seek to assess the national frequencies of parenteral nutrition (PN) use among hospitalized patients with IBD and to determine their in-hospital outcomes. METHODS: We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the frequency of PN usage among patients with UC or CD and to determine their in-hospital outcomes. A multivariate analysis was performed to identify factors predictive of increased inpatient mortality in this population. RESULTS: From 1988-2006, the annual incidence of PN use among hospitalized patients with CD was 4.29 per 100,000 and among those with UC was 3.80 per 100,000, with trends being relatively stable through the indexed period. The mean length of hospitalization among patients with UC receiving PN was longer compared with patients with CD. Factors predictive of an increased risk for mortality include the following: age >50 years, acute kidney injury, hospital-acquired pneumonia, Clostridium difficile colitis, prolonged postoperative ileus requiring PN use, pulmonary embolism, malnutrition, and patients with UC relative to CD. CONCLUSION: Traditionally, patients with CD are at a higher risk for developing malnutrition than patients with UC; however, there is a 2-fold higher risk for inpatient mortality and a longer length of hospitalization among patients with UC compared with those with CD. This pattern suggests that the use of PN, particularly among patients with UC, serves as a surrogate marker of higher disease acuity and severity.